Leg Length And Gait Cycle Flashcards
Short leg syndrome
Any condition in which an anatomical or functional leg length discrepancy results in
- sacral base unleveling (lower on the side of short leg)
- compensatory vertebral sidebending and rotation
- innominate rotations (usually anterior innominate rotation towards the short leg and posterior innominate rotation towards the long leg)
can be anatomical or functional
Anatomical vs functional
Anatomical
- an actually length discrepancy in the individual bones themselves, cant be attributed to a somatic dysfunction.
- cant be fixed by OMM and needs surgical intervention or orthopedic inserts to correct
Functional
- a length discrepancy that is actually caused by a somatic dysfunction in the body else where.
- can be fixed by OMM and orthopedic inserts. Never needs surgery.
All signs and symptoms of short leg syndrome
Sacral base unleveling (lower on short leg side)
Anterior innominate rotation on side of anatomic short leg
Posterior innominate rotation on the side of the anatomic long leg
Spinal curve will sidebend away from the short leg and rotate toward the long leg
Lumbosacral (Ferguson’s angle) will increase 2-3 degrees
Pelvis side-shifts toward the sides of the anatomical long leg
Neck/back/hip/knee/ankle pain
Asymmetric tightness of the psoas/glutei/piriformis/hamstrings on the anatomical short leg side
Internal rotation and pronation of the foot on the anatomical long leg side
(+/-) sciatica
How to evaluate for a short leg syndrome
Check for uneven shoe wear and tear
Screen for scoliosis
- Sidebending occurs away from the anatomical short leg
Check for asymmetries
Check standing flexion test
Measure leg lengths while supine
- should not line up with standing flexion test
any sacral base unleveling (SUB) >5mm should be assumed to be short leg syndrome and needs imaging and further work up
How do you measure leg lengths for anatomical short leg syndrome ?
Measure either from the ASIS or the superior aspect or the greater trochanter down to the inferior aspect of the medial malleolus with a tape measurer
A discrepancy of 6mm or greater (1/4 inch) = short leg syndrome on the shorter side
- must treat all somatic dysfunctions (especially pelvis/sacrum and thoracolumbar spine) first before measuring for anatomical short leg syndrome
Treatment of short leg syndrome
1) always remove any somatic dysfunction that is present
2) if it still exists, order xrays or leg length scanograms (CT of supine leg lengths)
- consider heel lifts if > 5mm is present
- also should check medial history for trauma/radiation/tumor/etc.*
How to get Sacral base unleveling measurements
1) Draw a reference line that is perpendicular on the film that goes straight down the sacral base
- in short leg syndrome, this line will usually not cross the pubic symphysis equally
2) get weight bearing lines by drawing a line vertically from the top of the femoral head and to the same level as the top of the reference line.
3) to get sacral base unleveling, find the groove where the sacral ala and superior articular process of the sacrum meet. Draw a horizontal line on both sides to the reference line, and crossing the weight baring lines
4) at the Point where the sacral base unleveling line crosses the weight baring line, draw a perpendicular line on both sides to the reference lines.
5) Measure the distance between the two lines in the previous step and divide by 2. This equals the true sacral base unleveling (SBU) distance
6) also check pelvic rotation by looking at the natal crease (top of the buttcrack). It should be along the reference line, if not then it is rotated
HEILIG formula
Formula used to determine the size of the heel lift to use in an anatomical short leg syndrome
L = SBU / (D+C)
- L = heel lift
- SBU = amount of sacral base unleveling
- D = time present
(1 = 1-10yrs; 11-30 yrs; 3 = 30+ yrs) - C = amount of compensation
(0 = sidebending only ; 1= rotation toward the convexity; 2 wedging/altered facets are present)
How to measure if lift therapy is working
Reassess everything 2 weeks
Unstable (osteoporosis/acute pain/elderly/arthritis present) patient = must start with 1/16”
Stable patient = can start with 1/8” or whatever was calculated by HELIG formula
- DONT replace by more then 1/4” at a time*
- this will induce contralateral pelvic rotation
Maximum heel lift possible is 1/2”. If they need more then need to use anterior sole lift
Side notes with leg lengths
If foot is pronated, use orthotic to correct possible pes planus
Lift must be used in each pair of shoes a patient wears
Start slow (an hour or 2 a day) dont start all day immediately (lots of back pain)
One “gait cycle”
Heel strike to next heel strike of the same foot (2 steps)
- 60% = stand phase
- 40% = swing phase
Stance phase subgroups
Initial double stance (10% of total gait cycle)
Single limb stance both right and left (40%)
Terminal double limb stance (10%)
the remaining 40% is in the swing phase
Average stride length and cadence?
Stride length = 28-32 inches
Cadence = 90-120 steps per minute
- women tend to be faster by 6-9 steps since they are often walking next to taller males
average speed is 3 mph
Stance phase sub phase names
Initial contact (first heel strike)
- ipsilateral innominate rotates posteriorly to allow hip flexion
- contralateral innominate rotates anteriorly to allow hip extension
Loading
- shock absorbed and weight bearing begins
Midstance
- limb/trunk stability is key
Terminal (final heel strike)
- Heel off leg is still contacting ground but is preparing to come off into swing phase
Pre-swing
- weight is released from stationary foot and limb is being positioned for swing
- thoracic vertebra rotates opposite swing foot
- lumbar vertebra rotates towards swing foot and side bends away from swing foot
- sacrum moves along the opposite oblique axis to the swing foot and locks the opposite SI joint up
Swing phase sub phases
Initial swing (early swing) - preparing foot clearance from floor
Mid swing
- contralateral foot is in mid stance phase
- foot is cleared an advancement is being conducted
Terminal swing (late swing)
- preparing limb for stance phase
- complete limb advancement has occurred
Why is waddling not efficient for gait?
It locks up both SI joints, so the sacrum cant rotate along the oblique axis well
- this causes the person to have to hike the hips to walk which is increased expenditure of energy and inefficient
Typical abnormal gaits and typical reasons for them
Antalgic gait = pain/injury
- short stand on injured side
- long stand on healthy side
Ataxic = cerebellar dysfunction
- wide stance to maintain balance
- patient with sway towards the side of the injury
- CANNOT walk in tandem gaits
Choreiform = hyperkinetic involuntary motions from pathology (Huntington’s, Sydenham chorea)
- jerky erratic gaits that dont add up in stance times
Diplegic = cerebral palsy
- “scissoring” of the legs and narrow base
- tight adductor muscles and toe walks in addition (extensor spasms)
Hemiplegic = stroke/TIA
- extend lower extremity and flexed upper extremity
- swing phase involves internal rotation and circumduction of leg (no dorsiflexion possible)
Myopathic = waddling movement dysfunction
- trendelenburg and hyper lordosis patients
High stoppage/equine gait = neuropathic dysfunctions (specific nerves usually)
- foot drop is most common
Shuffling/Bradykinetic = Parkinson’s
Huntington’s disease information
Caused by triplets in the Huntington gene on chromsome 4 short arm.
- “CAG” triplets in the huntin protein
Goals of short leg treatment
Correction of postural defects
Alleviation or decreased pain
Shift of body weight
Overall realignment of biomechanics of MSK
must treat all somatic dysfunctions in the pelvis, sacrum, thoracolumbar spine, lower extremity.
Ilizarov Procedure
Used to lengthen a signification shorter limb
Break the limb and attach the external fixator that is adjusted up to 4 times a day lengthening the fracture by 1mm a day
not really used anymore since its super painful
8 phases of the walking gait and the functions
1) initial heel strike
- establish contact with leading foot
- BEGINS STANCE
2) loading response/flat foot
- shock absorption
- BEGINS WEIGHT-BEARING
3) Mid-stance
- Limb & trunk stability
- progression over stationary
4) heel lift/off (terminal stance)
- progression past stationary foot
- prepare for swing
5) pre-swing/ toe-off
- weight release from stationary foot
- position limb for swing
6) Initial swing/ early swing
- prepare for foot clearance
- advance foot from trailing position
7) mid-swing
- foot clearance
- limb advancement
8) Terminal swing/ late swing
- prepare for stance
- complete limb advancement
Requirements for normal gait
Stability in stance
Foot clearance in swing
Prepare for initial contact
Adequate step length
Energy conservation
what motions are required to properly coordinate foot clearance in a swing of the entire limb
Ankle dorsiflexion
Knee flexion
Hip flexion
also requires motion to be allowed in the sacrum and innominates
What are the results of step length being too short and too long?
Too short
- minimal progress for amount of energy used (not efficient)
Too long
- lose balance
- strain ligaments and muscles
How does lumbar and sacrum move during pressing/toe off phase?
(Assume right leg is toe off leg)
Pressing/toe off:
1) thoracic:
- rotates opposite toe-off leg
2) lumbar:
- rotates towards toe-off leg
- side-bends opposite toe-off leg
3) sacrum:
- moves left along a left oblique axis
- left SI joint bears weight and allows right side to move
- sacrum rotates opposite lumbar rotation
How does lumbar and sacrum move during initial swing phase?
Assume right leg is initial swing phase leg
Right leg/innominate:
- hamstrings tense up
- slight posterior innominate rotation
- weight swings to left side
Sacrum:
- rotates forward along the left oblique axis
How does the pelvis move in inital contact phase of gait?
Foot that is coming out of swing to be in stance (anterior leg):
- ipsilateral innominate rotates posteriorly (leg can swing forward and hip flexion occurs)
- deep sacral sulci occurs here
Foot that is coming out of stance phase (posterior leg):
- ipsilateral innominate rotates anteriorly (leg can swing backwards and hip extension occurs)
What side during the gait cycle always has a deep sacral sulci?
The side where weight is on (side that is currently in stance phase)
What happens to the trunk and pelvis once mid stance phase occurs?
Everything begins to reverse itself
How does weight bearing and gait cycle correlate with sacral movement?
Which ever side has the stance/weight bearing leg = ipsilateral on ipsilateral sacral torsion.
Pathological gait
Abnormal gait cycle that is caused by some sort of pathology
Most common bacterial and viral causes of Guillain-Barré syndrome (GBS)?
Bacterial = campylobacter jejuni
Viral = influenza/CMV
Antalgic gait specifics
Typically seen in patients with injured bones/joints in lower extremities
Results in:
- shorted stance phase on affected leg
- lengthening stance phase on healthy leg (contralateral)
Ataxic gait specifics
Almost exclusively seen in cerebellar dysfunction/injury
Results in:
- wide stance for gait cycle
- patient will sway towards the side of the injury
- “intoxicated patient taking a soberity test”
Diplegic gait specifics
Typically seen in patients with cerebral palsy
Results in:
- extensor spasms/toe walking throughout gait cycle
- narrow base throughout gait cycle = drags legs/feet
- tonically tight adductor muscles = crosses legs naturally during gait cycle (“Scissoring”)
Hemiplegic or spastic gaits
Typically seen in stroke patients
Results in:
- flexed upper extremity on ipsilateral side
- extended lower extremity on ipsilateral side
- circumduction and internal rotation of ipsilateral leg during swing phase of gait cycle
Myopathic gait specifics
Results usually from gluteus Maximus or medius weakness
Results in:
- trendelenburg effect (contralateral hip tilts down during stance phase)
- hyperloridosis in lumbar region of neutral posture
Neuropathic gait
Also called high steppage/equine gait)
most common inherited neurologic disorder as well
Usually seen in patients with common perineal nerve injuries/impingement
Results in:
- tonic hip/knee flexion
- foot drop during swing phase
