Extension Thrust Gait /Varus Thrust Gait

Getting inside Dr. Allen's head again:

Last night i was asked to watch a client's gait and assist in the case. It was clear what we were seeing what initially was an "extension thrust gait" (note: i did not video the case, the video posted here is not the client but depicts an extension thrust well). The client had gradually also developed a Varus Thrust gait, which I have written about here several times in the last 2 months. The extension exaggeration often goes with the Varus Thrust gait. The do not have to be paired, but it is easier to go into Varus at the knee if one hyperextends first. Go ahead, stand and lock one knee back and feel the tendencies to move into varus slightly. Valgus is not likely in most people unless some predisposing OA welcomes it.
My point here today, is 2 fold.
These abnormal thrust variants are subtle at the start. To be the best you can be to your client, you have to find these problems in their infancy before they become enormous joint ranges that are impossible to correct, not to mention their soft tissue, ligament, and cartilaginous derangement and maceration. In the case I saw last night we added a sole lift to the entire foot-shoe.
Why? because a client that hyperextends also eats up some of the leg length by folding the knee posteriorly. This, when combining the extension thrust, and in their case, the varus thrust as well, it causes an Anterior Pelvis dumping on that same side, this facilitates further quad loading and thus further extension knee joint drive. It is a viscous cycle. See it in the video here, there seems no way out. The knee load is retrograde. This all creates a functional short leg, furthering the viscous loop. One has to bring the ground up to the shorter leg so help them "feel" the longer leg, thus helping them find the glute to help reorient the pelvis more posterior-ward, gait more finesse of the extensor mechanism (quads mostly). Then we added some kinesio-Rock tape to the posterior knee, applying it in relative knee flexion so that there was some biofeedback as to when they were exceeding knee neutral, moving too far into extension. This sensory motor relearning is critical, without it, they will be dependent upon devices. But the time the client left, with these in hand (foot :) : 2mm sole lift, awareness of aberrant knee extension strategy and varus thrust, how to co-contract the adductors to minimize the varus thrust and a neutral pelvis posture using more glutes (to also help them engage the adductors off the new neutral pelvis), and some flexible biofeedback tape application . . . . the client left with zero extension and varus thrust........and much work to do moving forward.
You have to see these things in their infancy, and that means you have to first recognize them, know how to negotiate around the numerous complicating components of all of them, and not train them deeper into it first of all. Recognize, restore, retrain.
Ala Neil Degrasse tyson: "facts, knowledge, wisdom, insight", . . . in that order.
PS: Oh, the client also had a deeply embedded scoliosis that i had to juggle (there were 5-6 balls going here at once) that was further driving the anterior pelvis drop on the affected side into a torsional pelvis distortion pattern. But, I didn't bring that up, and what i did with that component, because i didn't want anyone brain-barfing on their computer screen. Maybe another day :)

-Dr. Allen

https://www.youtube.com/watch?v=YjRoLtP1di0

Podcast 128: Usain Bolt, Plantaris Tears, Arm Swing

Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_128final.mp3

http://thegaitguys.libsyn.com/podcast-128-usain-bolt-plantaris-tears-arm-swing

https://www.thegaitguys.com/podcasts/

Key Tagwords:

usain bolt, plantaris tear, plantaris, sole lifts, heel lift, leg length, short leg, heel drop, shoeque, symmetry, asymmetry, sprinters, scoliosis, tendinopathy, achilles, runners, marathons, running injuries, arm swing

Our Websites:
www.thegaitguys.com
summitchiroandrehab.com   doctorallen.co     shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Superficial plantar cutaneous sensation does not trigger barefoot running adaptations.

https://www.ncbi.nlm.nih.gov/pubmed/28728130

Arm swing
http://www.medicalnewstoday.com/articles/173680.php

Usain bolt
https://mobile.nytimes.com/2017/07/20/sports/olympics/usain-bolt-stride-speed.html?referer=

Plantaris tears
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978447/

Leg length discrepancies and total joint replacments.

5mm cut off ?  MaybeYou are likely to come across hip and knee arthroplasty clients (total joint replacements). When they take a joint out and replace it with a new one, it can be a true challenge to restore leg lengths to equality side to side. Problems often arise down the road once gait is resumed and rehabilitation is completed. It can take time for the leg length discrepancy (LLD) to begin to create compensatory problems. This article seems to suggest that 5mm is the tipping point where gait changes becoming a problem are founded. Other sources will render different numbers, this article found 5mm. The authors found that both over- and underrestoration of leg length/offset showed similar effects on gait and that Gait analysis was able to assess restoration of biomechanics after hip replacement.  I would chose to use the word “change” over restore, since the gait analysis is merely showing the deployed strategies and compensations, never the problem.  But it is a tool, and gait analysis can be a decent tool to show “change”.*Remember, it is not always a product of true length, it can come from the pelvis posturing and/or from the acetabular orrientation, which can be a postoperative sequella. One cannot over look  acetabular inclination, anteversion and femoral component anteversion/retroversion issues.Just remember, before you start making LLD changes with inserts, cork, orthotics etc be sure that you have restored as best as possible, pelvis-hip-spine mechanics because changes here can reflect as a mere leg length discrepancy. And it goes the other way as well, a LLD can cause those changes above.

* Just use your brain and don’t just lift the heel, give them a full sole lift. Heel lifts for this problem are newbie mistakes. Don’t be a newbie.

- Dr. Shawn Allen

Leg length and offset differences above 5 mm after total hip arthroplasty are associated with altered gait kinematicsTobias Renkawitz, Tim Weber, Silvia Dullien, Michael Woerner, Sebastian Dendorfer, Joachim Grifka,Markus Weber
http://www.gaitposture.com/article/S0966-6362(16)30148-5/abstract?platform=hootsuite

Hmmm..What’s going on here? Can you see it?

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. 

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.

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

So a patient presents to your office with a recent history of a L total knee replacement 8 weeks ago AND a recent history of a resurgence of low back pain, supra iliac area on the L side. Hmmmm. Hope the flags went up for you too!

His global lumbar ROM’s were 70/90 flexion with low back discomfort at the lumbo sacral junction, 20/30 extension with lumbosacral discomfort, left lateral bending 10 degrees with increased pain (reproduction); right lateral bending 20 degrees with a pulling sensation on the right. Extension and axial compression of the lumbar spine in left lateral bending reproduced his pain.

Neurologically he had an absent patellar reflex on the left, with diminished sensation over the knee medially and laterally. Muscle strength 5/5 in LE; sl impaired balance in Left single leg standing. There was incomplete extension of the left knee, being at 5 degrees flexion (right side was zero).

He has a right sided leg length deficiency (or a left sided excess!) of 5 mm. Take a look at the tibial lengths in the 1st 3 pictures. See how the left is longer? In the next shot, do you see how the knee cannot completely extend? Can you imagine that the discrepancy would probably be larger if it did?

Now look at the x rays. We drew a line across from the non surgical leg to make things clearer.

Now, think about the mechanics of a longer leg. That leg will usually pronate more in an attempt to shorten the leg, and the opposite side will supinate to attempt to lengthen. Can you see how this would cause clockwise pelvic rotation (in addition to anterior pelvic rotation)? Can you see this patients in the view of the knees from the top? Do you understand that the lumbar spine has very limited rotation (about 5-10 degrees, with more movement superiorly (1)  ). Does it make sense that the increased range of motion could effect the disc and facet joints and increase the patients low back pain?

So, how do we fix it? Have you seen the movie “Gattica”? Hmmm….A bit extreme. How about a full length 3mm sole lift to start, along with specific joint manipulation to restore normal motion and some acupuncture to reduce inflammation? We say that is a good start.

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, please send it to someone else for them to enjoy and learn. 

(1) Three-Dimensional In Vivo Measurement of Lumbar Spine Segmental Motion Ruth S. Ochia, PhD, Nozomu Inoue, MD, PhD, Susan M. Renner, MS, Eric P. Lorenz, MS, Tae-Hong Lim, PhD, Gunnar B. Andersson, J. MD, PhD, Howard S. An, MD Spine. 2006;31(15):2073-2078.

Podcast #18: Treadmills, 'Shrooms & Santa

If you do not split a gut laughing by the time the band plays there is something wrong with you ! Who says gait stuff isn’t entertaining !
Perhaps our best podcast to date ? You decide.

Permalink URL
http://thegaitguys.libsyn.com/pod-18-treadmills-shrooms-santa

itunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Topics: Treadmills, neuroreceptors, foot types, hip biomechanixcs, gait cycle

Neuroscience piece link:

http://www.cannabisculture.com/articles/3136.html

1. from Eric on our FB page:

a. Had a 9yr old girl for a shoe fitting recently. She had a forefoot valgus, with a rearfoot that is neutral or slightly varus. Fairly high arch and rigid Midfoot for a child that age as well. usually a child’s foot is super flexible so this makes me wonder if it’s a compensation for a true FF varus. How do I tell if he has an anatomic FF valgus vs a compensated version?

b. I asked Blaise Dubois his opinion on Treadmill vs outdoor running and he mentioned that the literature indicates TM’s aren’t much different than outdoor. He cites (Wank 1998). To me, running feels completely different and I can’t run nearly as efficiently on a TM as outdoor. i know some people are the opposite, which i subscribe to specificity of training.

the question i have is what basis do you use for your opinion on different motor patterns? i agree with you, but the literature seems to disagree. this is a piece from cybex so of course it will be “pro-treadmill”, but they quote several studies that concur with Wank… http://media.cybexintl.com/cybexinstitute/research/Truth_on_Fit_Apr10.pdf

hope i’m not sending too many questions. i figure you can ignore them if you have too many from other listeners.

http://media.cybexintl.com/cybexinstitute/research/Truth_on_Fit_Apr10.pdf
media.cybexintl.com
2. On the Hip Bio Pt 6 you mention ext rot leg to gain leg length.  This one has been racking my brain.  I could see how this could happen if the person supinates the foot at the same time, but is there some other external rotating mechanism occurring in the hip that would cause this lengthening?  Thanks,Ryan

___________

Hi Gait Guys,

I am a chiropractor in South Africa, and find gait, biomechanics and running fascinating…I’m hoping to become a true gait geek one day.Reading your blog has taught me so much, you guys seem to look at gait from every angle and don’t take things at face value.

I would like to find out about your Shoe Fit Certification Program. Can people from outside the USA complete the course? Would I be able to take the exam online? and would it give me any creditation in South Africa

 Hope to hear from you soon.

 Regards, Claire

3. I have been watching your video’s on you tube.  I have a cavus foot in which I have had severe nerve pain, why is the high arch caused by nerve pain?

And would any of your exercises help with my nerve pain

Thanks,Wendy

___________
4. Hi guys,
Found your youtube channel. Very interesting stuff. Have started reading up on the whole gait cycle. Its very interesting.
I have a quick question that I hope that you can help me with:
Are you aware of any correlation of hip impingement (cam/pincer) in terms of having an irregular gait cycle?
I am suffering from both CAM & PINCER impingement in my right hip. Had surgery in January, but they did not shave sufficiently off the bone, so going back to surgery soon.
I am therefore interested in seeing how surgery possible could help me with bettering my walk and strain on my lower back / leg / foot. And also in terms of looking into some theory on how to retrain myself in walking cycles.
The problem is, that this kind of rehab/research is not available here in Denmark. So would appreciate if you are aware of any research on the above, and would be able to point me in the direction of that.
Thank you – and keep those great videos coming. :-)
Best,
Terje (Denmark)

More on Leg Length Discrepancies

Hi Guys,

I hope you guys are well?

I have a question I hope you can help me with?

Last week I assessed an entire football team, and over 90% have some sort of Leg Length Discrepancy (LLD). I am working with the physiotherapist to improve their weaknesses, including using sole lifts.

My question is if it’s a tibial short leg, then a lift with align the knee and hip. But a lift in a leg with a short femur will align the pelvis but raise the knee higher than the other side. Would you still insert a sole raise, and if not, what would you do?

Kind Regards

Luke

____________

Hi Luke

Yes, you are correct in your assumption of the change in mechanics, and yes, most often, we prescribe a sole lift, if a lift is indicated. Keep in mind that if they are asymptomatic and test out well, a lift may not be indicated. Hope that helps. You can also search LLD on the blog; we have written extensively on it: http://thegaitguys.tumblr.com

Remember sole lifts will correct the LLD but it could shift the pelvis off further…….many LLDs are from pelvic asymmetry and core weakness, this encompasses hip rotation differences which is a typical response to the core and pelvis that is distorted. 
merely forcing a change at the Sole does not mean you are making the positive change at the top……however it may in some cases……you have to determine that with your evaluations.

Most folks legs are of symmetrical length……..the changes at the top (core / pelvis/ hip) is what throws the apparent length off.

i wish i had a good answer for your great insight……..but it is about
1- making the right changes……..so that all parts are in cooperation for the restoration change
2- that you are directing change and not a further body compensattion to the compensation you have forced…….(if it is in fact a forced compensation and not the correction you are hoping for)….. time and re-evals will determine this
3- after restoration and strengthenging you must quickly wean off the lifts from them
4- you are speaking of tibial and femoral short………those are structural short LLDs , make sure you know if you are dealing with functional or structural shortness

Hope that Helps

Ivo and Shawn

MORE compensations for short legs…

We remember from 2 weeks ago, the week before, AND last week, there at least SIX common compensations for a short leg.

We spoke about circumducting the long leg last time. Once again, here is the list

•  pronation of the longer side, supination of the shorter
• leaning to he shorter leg side
• circumduction of the longer leg around the shorter
•  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
• excessive ankle plantar flexion on short side
•  excessive knee bend on the long leg side

Lets look at “hip hiking” of the longer extremity today. Hiking the hip allows one to create enough room (hopefully) to get that long leg through without dragging on the ground. Again,  it makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the longer leg.

This gal in the video has cerebral palsy (CP), affecting the left side. She has a short R leg and hikes the L pelvis pelvis up to get it to clear (she has L g med weakness due to the CP)

Watch the above video a few times to see what we are talking about. You can really see it when she is walking toward you.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Hip Hiking. Not quite the “Walk in the Woods” Bill Bryson was talking about, but yet another compensation for a short leg.

Ivo and Shawn. …bald, good looking, geeky…… The Gait Guys

* remember: by clicking on the YOUTUBE logo in the lower right you will be immediately linked to a larger viewing screen on youtube.

This is a video case of a triathlete who presented with left calf pain and right quadriceps leg pain after months of training. In the video we discuss altered ankle rocker (dorsiflexion), lower crossed syndrome, altered arm swing patterning, unilateral quadriceps tightness and several other functional gait pathologies with this case.

There is more than one way around a long leg…..
or…There are many compensations for a short leg

The 1st in a series…

You have heard us speak on LLD’s (leg length deficiencies) in previous posts here, here and here; but how about the compensations? What will you see visually?

We count about six common adaptations:

•  pronation of longer side, supination of shorter side
•  lean of torso to the short leg side
• circumduction of the longer leg around the shorter
•  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
• excessive ankle plantar flexion on short side
•  excessive knee bend on the long leg side

The thing to remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Lets look at the pronation/ supination scenario:

We often (but not always) see increased pronation on the longer leg side, in the bodies attempt to shorten the extremity. This is often accompanied by posterior rotation of the ilia on that side, resulting in saggital plane imbalances. This, of course, puts the external and internal obliques, as well as quadratus lumborum on that side in a shortened position, decreasing their mechanical efficiency. This all contributes to a loss of hip extension and usually, a loss of ankle rocker.

How about transverse plane changes? The lower extremity spins internally which places the vastus lateralis in a position of mechanical advantage, and the gluteus maximus and middle and posterior fibers of the gluteus medius in lengthened position, decreasing their efficiency, while placing the anterior fibers of the medius and minimus in a position of increased mechanical advantage. These changes will often contribute to changes in the frontal plane, often causing a “shift” to one side during walking and running gait.

Frontal plane dysfunction will be determined by the degree of functional leg length discrepancy created, along with how the other compensations are playing out.

Wow! Really, six compensations for a short leg? There are many more, these are only the most common ones we see. You probably see others in your analysis we haven’t mentioned here.

Stay tuned for more on this subject in future posts!

We are THE Gait Guys. Not set on world domination, just foot and gait literacy…

External Tibial Torsion as expressed during gait.

So, last week we watched this young lad doing some static ankle and knee bends, essentially some mini squats.  Here was what we found (LINK). It is IMPERATIVE that you watch this LINK first before watching today’s video above.

Now that you have watched that link here is what you should be seeing today.

You should see that the left foot is extremely turned out. We talked about why in the linked post from last week. It is because of the degree of external tibial torsion.  When it is present the knee rides inside the foot progression line (the knee bends into the forward / sagittal plane when the ankle bends into its more lateral /coronal / frontal plane (they all mean the same thing) ie. when the foot points outwards.

Remember, the knee has only one choice of motion, to hinge forward and backward. When the knee is asked to hinge in any other direction once the foot is locked to the ground there is torque placed upon the knee joint and thus shear forces.  Menisci do not like shear forces, nor does articular joint cartilage.

So, once again we see the rule of “you cannot beat the brain” playing out. The brain took the joint with the least amount of tolerance, the knee, and gave it the easy job.  The foot was asked to entertain another plane of motion as evidenced here in this video with significant increased foot progression angle. 

When the foot progression angle is increased but the knee still must follow the forward body progression (instead of following the foot direction) the motion through the foot will be directly through the medial longitudinal foot arch.  And as seen here, over time this arch will fail and collapse. 

Essentially this lad is hinging the ankle sagittally / forward through the subtalar and midtarsal joints, instead of through the ankle mortise joint where ankle hinging normally should occur.

This is a recipe for disaster. As you can see here.  You MUST also know and see here that there is an obvious limp down onto that left limb. It appears the left limb is shorter. And with this degree of external tibial torsion and the excessive degree of foot pronation, the limb will be shorter. You need to know that internal limb spin and pronation both functionally shorten the limb length.  This fella amongst other functional things is going to need a full length sole lift. We will start with 3mm rubber infused cork to do so. And let him accomodate to that to start.

We will attempt to correct as much foot tripod (anti-pronation) control as possible to help reduce leg shortness as well as to help reduce long term damage to the foot from this excessive pronation. We will also strengthen the left gluteus medius (it was very weak) to help him engage the frontal/lateral/coronal plane better. This may bring that foot in a little. But remember, the foot cannot come in so far that it drives the knee medially. Remember who is ruling the roost here !…… the knee.  It only has one free range, the hip and foot have 3 ! 

Shawn and Ivo

We could have easily made this a blog post about shoe sizes or how to use the Brannock device. And maybe we will in time. But this picture, if you are really thinking, can give you more insight into the entire biomechanical flaw of a client. If you read our post today we bet you will forever look and compare the size of both feet of your clients … forever !

This is a picture of one of our patients. This person had a congenital “club foot” at birth also know as congenital talipes equinovarus (CTEV). It is a congenital deformity involving one or both feet. In this case it affected on the right foot (the smaller one). Multiple surgeries were performed at an infant to correct, and the correction is beautiful as these things go. TEV is classified into 2 groups: Postural TEV or Structural TEV.

That all aside, we have a smaller shorter right foot.

Where are we going with this ?

Foot size is often measured with the Brannock device in shoe stores, you know, the weird looking thing with the slider that measures foot length and width. In this case, the right heel:ball ratio, the length from the heel to the first metatarsal head, is shorter. The heel:toe length is also shorter, nothing like stating the obvious ! IF they are shorter then the plantar fascia is shorter, the bones are shorter, the muscles are smaller etc.

So, taking yesterday’s blog post in tow here (LINK to that posting), the maximal height of the arch on the right when the foot is fully supinated is less than that of the left side when also fully supinated (ie. during the second half of the stance phase of gait). Even with maximal strength of the toe extensors which we spoke of yesterday will not sufficiently raise the arch on the right to the degree of the left.

1. Thus, this client is very likely to have a structural short leg. Certainly you must confirm it but you will likely see it in their gait if you look close enough.
2. Also, you must remember that the shorter foot will also spend fractionally less time on the ground and will reach toe off quicker than the left. This may also play into a subtle limp.
3. This client may have a mal-fitting shoe, the right foot will swim a little in a shoe that fits correctly on the left. You may be easily able to remedy all issues with a cork full length sole insert lifting both the heel and forefoot. This can negate the shoe size differential, change the toe off timing and remedy much of the short leg issue. * IMPORTANT: keep in mind, if you know your shoe anatomy (and you will if you get on board with our very soon to release “Shoe Fit Course”) you will know that the right foot at the metatarsal-phalangeal joint bending line will not be flexing where the shoe flexes on that right foot. The Right foot will be trying to bend proximal to the siping line where the shoe is supposed to naturally bend. This will place more stress into that foot. This brings up the rule for shoe fit: never size a persons shoe by pinching the toebox to see if there is ample room, the shoe should be fit to meet the great toe bend point to the flex point of the shoe.
4. Strength of muscles is directly proportional to the cross sectional area of the muscle. With smaller muscles, this right limb is very likely to be underpowered when compared to the left.
5. All of these issues can cause a failure of symmetrical hip rotation and pelvic distortion patterning.
6. Altered arm swing (most likely on the contralateral side) is very likely to accommodate to the smaller weaker right lower limb. Do not be surprised to hear about low back pain or tightness or neck/shoulder issues.
7. A shorter right leg, due to the issues we have discussed above, will place more impact load into the right hip ( from stepping down into the shorter leg) and more compressive load into the left hip (due to more demand on the left gluteus medius to attempt to lift the shorter leg during the right leg swing phase). This will also challenge the pelvic symmetry and can cause some minor frontal plane lumbar spine architecture changes (structural or functional scoliosis…… if you want to drop such a heavy term on it).

Gait plays deeply into everything. Never underestimate any asymmetry in the body. Some part as to take up the slack or take the hit.

Shawn and Ivo…….. far from symmetrical lads.

Clinical Video Case Study: Tibial Varum with added Post-op ACL complications.

This is a case of ours. This young man had a left total knee reconstruction (Left ACL and posterolateral compartment reconstruction; allograft ligaments for both areas). This video is roughly 3 months post surgery.

Q: What anatomical variants are seen in this individual?

A: Note the genu and tibial varum present. This results in an increased amount of pronation necessary (right greater than left, because of an apparent Left sided short leg length;

* NOTE: post-operatively at this point the client had still some loss of terminal left knee extension. thus the knee was in relative flexion and we know that a slightly flexed knee appears to be a shorter leg. Go ahead, stand and bend your left knee a few degrees, the body will present itself as a shorter leg on that left side with all the body compensations to follow such as right lateral hip shift and left upper torso shift to compensate to that pelvic compensation.)

Normally, in this type of scenario (although we have corrected much of it at this point by giving him more anterior compartment strength and strategy as evidenced by his accentuated toe extension and ankle dorsiflexion strategies, these are conscious strategies at this point for the patient), the functionally shorter left leg has a body mass acceleration down onto it off of the longer right leg stance phase of gait. This sagittal (forward) acceleration is met by a longer stride on the right with an abrupt heel strike (in other words, the client is moving faster than normal across the left stance phase so there is abrupt and delayed heel strike on the right because of a step length increase. (again, this is just commentary, had we videoed this client weeks before this, you would have seen these gait pathologies. This video shows him ~70% through a gait corrective phase with us.)

Again, this client has bilateral tibial varum. You can see this as evidence due to the increased calcaneal valgus (ie. rearfoot pronation; look at the achilles valgus presentation).
He increases his arm swing on the Left to help bring the longer Right lower extremity (relative) through.
if you look closely you can also see early right heel departure which is driven by the increased forward momentum of the body off of the short left limb. In other words, the body mass is moving forward faster than normal onto the right limb (because of the abbreviated time spend on the left “short” leg) and thus the forward propulsed body is pulling the right heel up early and the heel is spinning inwards creating a net external rotation on the right limb (look for the right foot to spin outwards/externally ever so slightly in the second half of the video).

Early heel departure means early mid and forefoot weight bearing challenges and thus reduced time to cope well with pronation challenges. As we see in this case where the right foot is pronating more heavily than the left. You can think of it this way as well, the brain will try to make a shorter leg longer by supinating the foot to raise the arch, and the longer leg will try to shorten by creating more arch collapse/pronation.