Subtle clues to an LLD?

Leg length discrepancies, whether their functional anatomical, have biomechanical consequences north of the foot. This low back pain patient exhibited 2 signs. Can you tell what they are?

can you see the difference ?

how about now?

compare right to left

compare right to left

can you see the difference in the Q angles?

Look at the first picture and noticed how the left knee is hyper extended compared to the right. Sometimes we see flexion of this extremity. This is to "functionally shorten" that extremity.

Now look at the Q angles. Can you see how the left QL angle is greater than the right? This usually results from a long-term leg length discrepancy where the body is attempting to compensate by increasing the valgus angle of that knee, effectively shortening the extremity.

Dr Ivo Waerlop, one of The Gait Guys

#subtle #clues #LLD #leglengthdiscrepancy #leglengthinequality #thegaitguys #gaitabnormality

On the road to a cruciate reconstruction?

While at a recent soccer game, I noticed this gal standing on the side lines. Talk about knee problems waiting to happen ! Note the hyperextended posture of the knees with increase in lumbar lordosis and anterior carriage of the entire pelvis with an increase in the thoracic kyphosis and head forward carriage to match! You can imagine the anterior pelvic tilt as well as stretch weakness of the abdominal obliques creating "core instability". At least she is not wearing heels, although a negative inclination [negative ramp delta] shoe would probably help.

Think of the strain on her poor posterior cruciate ligaments with all of that anterior femoral translation! We remember that the popliteus acts as an "accessory PCL" at initial contact in the gait cycle. It fires at heel strike and again from loading response until toe off

Think about the forces on these knees while descending hills or stairs. The momentum will carry the femur forward (or anteriorly). There needs to be something to reststrain this; enter the PCL. Because of the laxity (and instability), the poplitues will need to fire to take up the slack. We wrote about that here and here.

Note, this is a mere thought experiment, don’t get bent outta shape, these things might not occur, or they might. Time will tell.

Ganu Valgus and Kids

Here we look at genu valgus in kids. What she needs to know and how to keep track of it.

The Q angle and Kids: The Basics

Genu valgum in kids: What you need to know

We have all seen this. The kid with the awful “knock knees”.  It is a Latin word “which means “bent” or “knock kneed”. It appears to have 1st been used in 1884.

This condition, where the Q angle angle exceeds 15 degrees, usually presents maximally at age 3 and should resolve by age 9. It is usually physiologic in development due to obliquity of the femur, when the medial condyle is lower than the lateral. Normal development and weight bearing lead to an overgrowth of the medial condyle of the femur. This, combined with varying development of the medial and lateral epiphysies of the tibial plateau leads to the valgus development. Gradually, with increased weight bearing, the lateral femoral condyle (and thus the tibial epiphysis) bear more weight and this appears to slow, and eventually reverse the valgum.

Normal knee angulation usually progresses from 10-15 degrees varus at birth to a maximal valgus angle of 10-15 degreesat 3-3.5 years (see picture).  The valgus usually decreases to an adult angle of 5-7 degrees.  Remember that in women, the Q angle should be less than 22 degrees with the knee in extension and in men, less than 18 degrees. It is measured by measuring the angle between the line drawn from the ASIS to the center of the patella and one from the center of the patella through the tibial tuberosty, while the leg is extended.

Further evaluation of a child is probably indicated if:

• The angle is greater than 2 standard deviations for their age (see chart) 
• If their height is > 25th percentile 
• If it is increasing in severity 
• If it is developing asymmetrically

Management is by serial measurement of the intermalleolar distance (the distance between ankles when the child’s knee are placed together) to document gradual spontaneous resolution (hopefully). If physiologic genu valgum persists beyond 7-8 years of age, an orthopaedic referral would be indicated but certainly intervention with attempts at corrective exercises and gait therapy should be employed. Persistence in the adult can cause a myriad of gait, foot, patello femoral and hip disorders, and that is the topic on another post.

Promotion of good foot biomechanics through the use of minimally supportive shoes, encouraging walking on sand (time to take that trip to the beach!), walking on uneven surfaces (like rocks, dirt and gravel), gentle massage (to promote muscle facilitation for those muscles which test weak (origin/insertion work) and circulation), gait therapeutic exercises and acupuncture when indicated, can all be helpful.

The power to bend bones.

What have we here? Hmmm. This little girl was brought in by her mother because of intermittent knee pain and “collapsing” of the knees while walking, for no apparent reason.

The ankle dorsi flexion (or ankle rocker; see last 2 pictures; we are fully dorsiflexing the ankles)  needs to occur somewhere, how about the knees? Or in this case, the tibia. Wow!

You are looking at a 4 year year with a condition called genu (and tibial) recurvatum. Genu recurvatum is operationally defined as knee hyperextension greater than 5 degrees. The knee is hyperextended, and in this case, the tibia is literally “bent backward”. Look at the 2 pictures of her tibia.

Generally speaking, the tibial plateau usually has a slight posterior inclination (as it does in this case; look carefully at the 1st picture) causing the knee to flex slightly when standing. Sometimes, if it is parallel with the ground and the center of gravity is forward of the knees, the knee will hyperextend (or in this case, the tibia will bend) to compensate.

In this particular case, the tibia has compensated more, rather than the knee itself. The knee joint is stable and there is no ligamentous laxity as of yet. She does not have a neurological disorder, neuromuscular disease or connective tissue disorder. She has congenitally tight calves.

As you can imagine, her step length is abbreviated and ankle rocker is impaired.

So what did we tell her Mom?

• keep her barefoot as much as possible (incidentally, she loves to be barefoot most of the time, gee, go figure!)
• have her walk on her heels (she’s a kid, make a game of it)
• showed her how to do calf stretches
• balance on 1 leg with her eyes open and closed
• keep her out of backless shoes (like the clogs she came in with)
• keep her out of flip flops and sandals where she would have to “scrunch” her toes to keep them on.
• follow back in 3 months to reassess

There you have it. Next time you don’t think Wolff’s (or Davis’s) law* is real, think about this case. Want to know more? Consider taking our National Shoe Fit Program, available by clicking here.

The Gait Guys. Making you gait IQ higher with each post.

*Wolff’s law: Bone will be deposited in areas of stress and removed in areas of strain. or put another way: bone in a healthy person or animal will adapt to the loads under which it is placed

Davis’s law: soft tissue will adapt to the loads that are placed on it