Unilateral increased tibial varum; one reason why...

Take a look at this gent in the picture. Do you notice anything peculiar? Pick a point and start either moving from above down or from the ground up.

From the ground up, the first thing you may notice is that he has a hallux abducto valgus on the right side. This could be for any number of reasons and what it actually tells you is that he is unable to anchor his first ray to the ground and have appropriate function of the adductor hallucis. Your job, during the examination process, is to sort that out.

The second thing you may notice is that he has more midfoot collapse on this same side. You would think that with that much midfoot collapse he would get his first ray to the ground but that’s obviously not the case.

Moving up from there, you may have noticed that he has significantly more tibial varum on the left-hand side. Tibial varum should be about 4-6 degrees and is largely a function of in utero positioning although diseases like osteomalacia and rickets can increase it though this is often more bilaterally symmetrical.

You need to be aware increased tibial varum means that the foot, particularly the forefoot, needs to pronate a greater degree to create a stable foot tripod on the ground. You need to ensure during the examination process that adequate range of motion in the forefoot and 1st ray are available.

You may have noticed that there is prominence of the left medial head of the gastroc which is most likely a combination of positioning as well as increased mechanical advantage secondary to the varum.

Hopefully you noticed that the knees are (relatively) in the sagittal plane and that there’s an increase progression angle on the left-hand side. If you drop a plumbline from the tibial tuberosity you’ll see the falls medial to the second metatarsal shaft indicating external tibial torsion in the lower extremity.

The unilateral increased tibial varum on the left-hand side is secondary to an anatomical leg length discrepancy where the right tibia is shorter. This has been long-standing and in compensation, the left tibia has “bowed“ to compensate for the difference, In an attempt to shorten the left leg.

Dr Ivo Waerlop, one of The Gait Guys

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#tibialvarum #leglengthdiscrepancy #lld #bowedlegs #pronation

A novel way to look at functional internal rotation of the hips

As clinicians (and coaches) we are often trying to figure out different ways to functionally assess internal rotation of the hips. How many times does the patient/client “appear“ to have appropriate internal rotation on the table only to find out that they don’t functionally and vice versa.

Take a look at it this gentleman who is a ski instructor. We are trying to simulate the standard side to side ski motion in a way that would be functionally appropriate. Keep in mind that he has bilateral internal tibial torsion and bilateral femoral retro torsion. When he began care at our office he had 5° external rotation on the right and about 8° external rotation on the left as his FULL AMOUNT OF INTERNAL ROTATION AVAILABLE to him bilaterally.

Treatment consisted largely of hip mobilization, Therapeutic exercises to emphasize internal rotation of the hips such as hip helicopters, airplanes and supine “chairs“ with internal rotation and adduction utilizing a ball between the knees; we also did acupuncture/needling of the hip capsules as well as anterior fibers of the gluteus medius and minimus. He now has about 5° internal rotation on the right now and a little less than 5 on the left. Note how the motion is clearly visualized in this video below.

Do you have other novel ways to test internal rotation of the hips functionally? Leave a comment or drop us a line and let us know

Feel like you want more? Join us this Wednesday evening on onlinece.com for Biomechanics 326: 6 MST

Dr Ivo Waerlop, one of The Gait Guys.

#functionaltesting #functionalmovement #hip #internalrotation #femoralretrotorsion #femoralretroversion #thegaitguys

The Hip "Airplane"

Here’s another great hip strengthening exercise for the gluteus medius, minimus, deep six external rotators as well as proprioceptive components about the hip. It is often used in conjunction with the hip helicopter exercises.

Dr Ivo Waerlop, one of The Gait Guys

#hipairplaneexercise #hippain #deep6extrenalrotators #gaitguys #proprioception #proprioceptiveexercises #thegaitguys

https://vimeo.com/371217385

The Hip Helicopter Exercise

In this short video, Dr. Ivo Waerlop of The Gait Guys demonstrates an excellent hip strengthening exercise which incorporates all three tenants of skill, endurance, and strength. This pairs well with the hip airplane exercise.

What does "hip drop" look like?

Watch this gal running on a treadmill at a 1.5% grade at about a 10 minute mile pace. Note that when she is in stance phase on one leg, the contralateral side of the pelvis “drops“. Up to an inch of vertical oscillation of the entire pelvis is expected, but the unilateral “dip” often signals a problem.

The gluteus medius is also known as the “deltoid“ of the hip. It is active pretty much from the time the foot hits the ground until it leaves the ground ( all of stance phase). It is paired anatomically and neurologically with the contralateral quadratus lumborum. Together this pair helps to keep the pelvis level when walking with the gluteus medius pulling the pelvis up from the opposite side and the contralateral quadratus lumborum on the swing leg side lifting the pelvis up.

When you see the pelvis “dip”on the swing leg side or “cruise“ to the stance leg side, this generally means that there is some weakness of pelvic abduction. This can be due to a weakened gluteus medius on the stance leg side, weak quadratus lumborum on the swing leg side, both, or sometimes as a compensation for a leg length discrepancy.

Remediation would include closed chain exercises like hip helicopters and airplanes as well as penguin walks along with gait retraining of the stance leg gluteus medius and swing leg quadratus lumborum. We’ve had success utilizing K tape as well with an inverted triangle over the gluteus medium and an “X” pattern with a vertical strip on the lateral aspect for the quadratus.

Dr. Ivo Waerlop, one of The Gait Guys

#pelvicdip #gluteusmediusweakness #quadratuslumborum #hipdrop

The “ banana foot”

So, you see at foot that looks like this and what do you think? What are some of the biomechanical characteristics of people with the foot that when, you bisect the calcaneus, the line passing forward passes lateral to the second metatarsal or a line between the second and third?

This condition can be congenital, in conditions like forefoot adductus or compensatory.

The first thing that springs to mind when we see deformities like this is “things usually occur in threes“. So we would expect to see other anatomical and/or genetic abnormalities. An adducted forefoot, like you see here, often occurs as the result of lack of internal rotation of the hip on that side so therefore will often be present with conditions like internal tibial torsion and femoral retrotorsion, which we often, but not always, see together. Because of the increased gait and foot progression angle in these individuals, the forefoot compensates and adducts to bring the center of gravity more to midline.

Feet like this are often, but not always, cavus and rigid. If it remains in relative supination (plantarflexion, abduction and inversion) it is an excellent level but poor shock absorber.

Forefoot adduction can also be a compensation pattern if an individual is unable to get the head of their first ray completely down to the ground. It could be a true forefoot varus or more commonly, a forefoot supinatus; either results in an inability to get the first ray down. This often causes the foot to adduct in compensation, and, due to the tarsal articulations, often raises the base of the first metatarsal increasing the inclination angle of the first ray. This frequently leads to limited dorsiflexion of the first metatarsophalangeal articulation.

So what is a clinician to do?

Ensure that the mechanics of the foot are clean through manipulation and mobilization

Make sure there are appropriate flexors/extensor ratios of skill, endurance, and strength of the foot musculature both intrinsically and extrinsically. This means making sure that the long flexors and extensors are in some degree of balance.

Work on balance and coordination of the lower extremity. This can be impeded if they’re unable to get ahead of the first right down to the ground. Exercises for the peroneus longus, extensor hallucis brevis and short flexors of the foot will often help with this.

“Banana foot”. Coming to your clinic, or a clinic near you. Maybe today…

Dr. Ivo Waerlop, one of The Gait Guys.

#forefootadductus #bananafoot #supination #thegaitguys