Exploring the Links Between Human Movement, Biomechanics & Gait
Why does this gal have so much limited external rotation of her legs?
We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.
Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.
Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion. This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation. She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.
So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius, gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient.
confused? Did you miss our awesome post on femoral torsions: click here to learn more.
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.
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
Welcome to Monday, folks. Today Dr Ivo discusses why not all shoes are created equal and why you need to understand and educate your peeps about shoes!
Internal tibial torsion is when the foot is rotated internally with respect to the tibia. When the foot is straight (like when you are walking, because the brain will not let you walk too internally rotated because you will trip and fall), the knee will rotated OUTSIDE the saggital plane (knee points out). Putting a medially posted shoe on that foot rotates the foot EVEN FURTHER laterally. Since the knee is a hinge joint, this can spell disaster for the meniscus.
need to know more? email us or send us a message about our National Shoe Fit Program.
Manipulation of a joint appears to change the instantaneous axis of rotation of that joint (1). It would stand to reason that this change would effect muscle activation patterns (2). Can this be applied to the lower extremity? Apparently so, at least according to this paper (3).
“…The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.”
So, what does this mean?
The peroneus longus contracts from just after midstance to pre swing to assist in descending the 1st ray and assist in supination. The soleus contracts from loading response (medial portion, eccentrically, to slow calcaneal eversion) until just after midstance (to assist in calcanel inversion and supination).
The tibiofibular articulation is a dynamic structure during gait, and the fibula appears to move downward during the stance phase of gait (rather than upward, as previously thought from cadaver studies)(4), with the distal articulation having a rotational moment (5).
Consider checking the integrity of these joints, and asuring their proper ranges of motion, particularly in patients with chronic ankle instability (6). A little joint motion can go a long way : )
Got Motion Control? Sometimes too much of a good thing is a bad thing!
Welcome to Monday and News You can Use, Folks.
Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.
You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.
What were they thinking? Oh, they weren’t thinking…
Here is a simple case of knowing your anatomy.
make sure to use the toggle bar to the right and left of the picture to see all the pictures : )
This woman came in with right sided lateral knee pain with hiking and skiing; worse with fatigue, better with rest. The pain was localized at the lateral joint line and at the tibial fibular joint.
She had been previously been diagnosed with tibial fibular hypermobility and subsequently had an arthrodesis (fusion) performed at that joint for knee pain. The surgery helped for a short time and a newer, slightly different pain developed.
Yes, she has a moderate genu valgus, R > L. Yes, she has a left, anatomically short (tibial) Left leg. Yes, she has has NO MOBILITY at the tib/fib articulation and the focus of pain is just above at the joint line and at the lateral aspect of the patello femoral joint.
The tibial fibular joint is a syndesmosis (not a true synovial or diarthrodial joint) that is supposed to have a a superio/inferior gliding motion (see diagram) with ankle dorsiflexion, due to the wedge shape of the talar dome and talo crural articulation. It also is supposed to have an anterior/posterior gliding movement at the superior aspect of the joint and a reciprocal movement in the opposite direction at the ankle (see diagram).
Whenever we take away movement in one area, it needs to occur somewhere else; in this case, at the femoral tibial joint and patello femoral joints.
Does it make sense that her left sided leg would cause hypermobility on the right side with a supinatory moment of the foot on the left to attempt to lengthen the leg and a pronatory movement of the foot on the right, in addition to valgus angulation of the joint on the right to attempt to “shorten” that extremity? Would this increased valgus angluation of the knee, in turn, cause abnormal, lateral, tracking of the patella? Wouldn’t the increased pronatory moment cause a more supple foot on that side with increased requirements for “push off” on that side with increased calf recruitment? Do you think that may impair proprioception on that side?
What if you put a sole lift in the left shoe (like we did) to help to alleviate some of the discrepancy and gave her some anterior compartment exercises (toes up walking, lift/spread/reach exercises, heel walking, simple balance on 1 leg exercises? Her world becomes a much better place to live in and she can return to the activities she loves to do with her 65 year old friends, like hiking 14′ers, skiing and mountain biking,
What we do to one joint affects all the others. You cannot make one change without expecting others. Be on the lookout and know your anatomy! This case was relatively straight forward. Many are not. Do a thorough exam and expect the unexpected.
So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)
We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)
What would you do? Here’s what we did:
acupuncture to reduce swelling
took him out of his motion control shoes (which pitch him further outside the saggital plane)
gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
potty squats in a pain free range
asked him to avoid full flexion
Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!
Sometimes you need to run that valgus post clear back to the heel!
A valgus post assists in pronation. Some fols have modereate to severe internal tibial torsion and need to be able to pronate more to get the knee into the saggital plane for patello femoral conflicts. They usually run from the tail of the 5th metatarsal forward, but sometimes need to run it clear back to the heel to get enough pronation to occur.
This 7 year old girl is brought in by her mother because of knee misalignment while skiing, L > R. No history of trauma; normal term birth with no complications. No knee pain. Of incidental note, she is deaf in the left ear.
She has bi-lat. external tibial torsion, left much worse than right (40 degrees transmallolear angle vs 22 degrees. for info on measuring torsions, click here). remember, you should be able to draw a line from the tibial tuberosity down through the 2nd metatarsal head.
She has a 5mm anatomical leg length deficiency on the right (see top above left).
She has femoral antetorsion right side with very little external rotation, approximately 10 degrees, internal rotation is in excess of 50. Left side has normal femoral versions (for a review of femoral versions and torsions, click here). See last 2 pictures which are full internal and external rotation respectively.
She has a mild uncompensated forefoot varus (cannot really see from the pictures, you will need to take our word for it) with a relatively cavus arch to her foot(see center and last picture on right.
Neurologically, she appeared to have integrity with respect to sensation, motor strength and deep tendon reflexes in the lower extremities.
Pathomechanical alignment as described. Severe left external tibial torsion. MIld to moderate right. Femoral antetorsion right.
We are going to build her a medium heel cup full length modified UCB orthotic inverting the cast bi-lat. left greater than right. We gave her balance and coordination exercises, heel walking, lift/spread/reach and one leg balancing. She will follow up for a dispense. Her mother will try to get a better fitting ski boot as the one she has currently is two sizes too big. She will return for a dispense. She should consider wearing the orthotics in everyday footwear as well. We will do a follow up post in a few weeks.
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