O - Abnormal Gait Flashcards
what are the pronatory functions of the foot (3)
- adaptation
- shock absorption
- torque conversion
pronation is normal
becomes a problem if excessive
what is the supinatory function of the foot
rigid lever -> heel raise as tibia moves over foot
what are the triplanar motions in pronation and their respective planes
DF - sagittal
ABD - transverse
eversion - frontal
what are the triplanar motions in supination and their respective planes
PF - sagittal
ADD - transverse
inversion - frontal
what 3 motions happen at the STJ during pronation in OKC
calcaneal:
* eversion
* ABD
* DF
same as the triplanar motions
what 3 motions happen at the STJ during supination in OKC
calcaneal:
* inversion
* ADD
* PF
same as triplanar motions
what 3 motions happen at the STJ during pronation in CKC
calcaneal eversion
talar ADD/PF
tibial IR
talar ADD/PF lowers arch, tibia has to IR bc of talar motion
what motion stays consistent b/w OKC and CKC pronation vs supination
in pronation - calcaneal eversion
in supination - calcaneal inversion
what happens up the chain during CKC pronation
calcaneal eversion
talar ADD/PF
tibial IR
knee flex
hip IR
ant pelvic tilt
inc lumbar lordosis
what 3 motions happen at the STJ during supination in CKC
calcaneal inversion
talar ABD/DF
tibial ER
talar ABD/DF - elevates arch
tibia follows talar motion
what happens up the chain during CKC supination
calcaneal inversion
talar ABD/DF
tibial ER
knee ext
hip ER
post pelvic tilt
dec lumbar lordosis
tibia ER - screw home mechanism
what are the components to look at for intrinsic normalcy
- post bisect calcaneus parallel to post bisect of lower 1/3 of leg
- MT heads perp to calcaneus bisection
- MT heads in same plane
- 10deg of ankle DF
STJ in neutral for these things
why don’t you measure DF by pushing straight back
measuring DF of multiple joints
why do you need 10deg of DF in STJ neutral
in late midstance:
* STJ supinating to prep for heel raise
* ankle/TC DF as tibia and body advances over limb
placing STJ in neutral mimics demands of gait
what is compensation
mvmt of one body part to neutralize the effects of a mvmt or alignment of another body part
what is normal compensation
allows for normal function
* compensatory pron or sup to allow for rotation higher in kinetic chain
what is excessive compensation
when motion required surpasses supportive tissue tolerance resulting in soft tissue trauma
* this is when people start to have problems and discomfort
what are the two goals during gait that the RF or FF might compensate for
- plantar surface of calcaneus to ground (RF)
- MT heads to ground (FF)
overall goal is to get foot flat on the ground
how could the RF compensate to get the plantar surface of calcaneus to ground (goal #1)
STJ may pron or sup
how might the FF compensate to get MT heads to the ground (goal #2)
STJ and MTJ may pron or sup
what in general does an uncompensated foot present with
RF or FF doesn’t reach flat contact w the ground
what are two reasons for an uncompensated foot presentation and which is the most common
STJ mobility (most common)
abnormal LE alignment
what foot type are uncompensated feet usually
more rigid - lack mobility to compensate
what do calluses form from
uneven weight distribution
* friction –> skin build up
abnormal shear forces
* biomechanical
after identifying a callus pattern what do you do w this info
NOT diagnostic
can use it to think ab a possible cause
describe normal STJ motion during:
* contact
* midstance
* propulsion
contact:
* STJ in slight sup at HS
* STJ pron 3-5deg by FF
midstance:
* STJ re-sup to neutral or slight sup
* need a rigid lever
* should be neutral by heel rise
propulsion:
* STJ cont to sup
what is subtalar varus and how is it measured
position of inversion
measure amt calcaneus inverted
varus if >4deg
why is subtalar a common foot type
born w ~10deg STJ varus
body derotates to neutral w age
reason for subtalar varus in OKC vs relaxed stance
OKC - incomplete derotation
relaxed - dynamic problem
relaxed stance - doesn’t look too bad, slight arch lowering
what is the main difference in dynamic function b/w normal STJ and compensated STJ varus
on contact:
* inc calcaneal inversion @HS
* inc STJ pronation to meet goal #1 (getting foot flat)
what is a common callus pattern for most hyperpronatory foot types
under 2nd and 3rd MT heads
what role does peroneus longus play in gait
stabilizing and holding foot to ground in CKC
as foot resupinates, holds foot to ground for a rigid lever
describe the callus pattern for compensated STJ and why
under 2nd and 3rd MT heads
* MTJ unstable
* peroneus longus not strong enough to stabilize 1st ray
* weight forces shift laterally to 2nd and 3rd
STJ varus compensated
how could spring ligament pathology be a resulting pathology and how would it present
talus moving down and in
calcaneus is everting
medial arch/ache pain
STJ varus compensated
how could plantar fascia pathology be a resulting pathology
plantar fascia is inelastic
* when talus displaced ant w/ pronation, drops down and in
* foot overpronates and get tension on periosteal attachment
* with excessive and repetitive tension can get a bony growth on calcaneus as it lays down more bone -> traction heel spur
STJ varus compensated
how can post tib tendinitis/tendinosis be a resulting pathology
being overused:
* working to decel pronation via ecc contraction after heel strike
* in midstance has to help resup - contracts conc and iso
* working too much
STJ varus compensated
how can trochanteric bursitis be a resulting pathology
femoral IR compensating for resulting tibial IR
* places shear forces on bursa
STJ varus compensated
how can patellofemoral dysfunction be a resulting pathology
places valgus thrust forces on knee
STJ varus compensated
how can medial knee pain be a resulting pathology
places strain on medial capsule and meniscus
STJ varus compensated
how can sinus tarsi syndrome be a resulting pathology and what are presenting sx
excessive pronation compresses lateral calcaneus and talus
diffuse pain ant to lat malleolus
* increased w WBing
* difficulty w uneven surfaces
STJ varus compensated
how can tarsal tunnel syndrome be a resulting pathology and what are presenting sx
talar displacement compresses post tib n.
burning, numbness, tingling on medial side
if getting those sx, screen lumbar spine and if that is neg then think tarsal tunnel syndrome
STJ varus compensated
what pt pop has a higher incidence of tarsal tunnel syndrome
DM
STJ varus compensated
what will and won’t address the shear forces
will - control pronation
won’t - padding
STJ varus compensated
what orthotic and footwear should be prescribed
biomechanical - medial RF post
motion control - duo density midsole
STJ varus compensated
what are 3 PT interventions
proximal weakness/hip IR - gluts
foot intrinsics
ecc tib post strength
STJ varus UNcompensated
how will this foot look in relaxed stance
hypomobile & stable
stays in inverted position
doesn’t have mobility to compensate
STJ varus compensated
how will this foot look in relaxed stance
not too bad - slight arch lowering
this is a dynamic problem
STJ varus UNcompensated
what does the dynamic function look like in gait
CONTACT
* inc calcaneal inversion @ HS
* dec STJ motion to compensate
MIDSTANCE
* calcaneus remains inverted
* lateral WB-ing
PROPULSION
* WB-ing shifts medially late as heel rises
STJ varus UNcompensated
what is the callus pattern and why
lateral border of foot
5th MT head
lateral WBing d/t lack of pronation
* lateral heel whip
STJ varus UNcompensated
what is the main reason for pathologies to result from this
not pronating, no shock absorption
GRF goes up the chain
STJ varus UNcompensated
what proximal sx can result
lateral knee
hip/LBP
STJ varus UNcompensated
what is haglund’s deformity
“pump bump”
posterolateral exostosis
this is common in rigid foot types
STJ varus UNcompensated
how could lateral ankle sprains be a resulting pathology
weight bearing staying lateral, easy to roll laterally
STJ varus UNcompensated
how can medial joint pain be a resulting pathology? how does it present? what are 2 alternative dx?
STJ compression
dull joint line ache
worse on hard surfaces or in shoes w inadequate shock absorption
plantar fasciitis
tib post tendon
STJ varus UNcompensated
what is the concern with a jones or dancers fx
high non union rate
STJ varus UNcompensated
what fx are common resulting pathologies
stress fx - tib/fib
jones - 5th shaft
dancers - base of 5th
not absorbing GRF forces
STJ varus UNcompensated
what PT intervention is appropriate
mobilizations to restore normal mobility
* subtalar
* midtarsal
* talocrural
STJ varus UNcompensated
what orthotic and footwear should be prescribed
orthotic - accommodative (softer)
footwear - cushion shoe
why will you only ever see RF varus or neutral, and not ever valgus
RF valgus would mean that they developmentally derotated past neutral
why is forefoot varus such a common foot type
born with 10-15deg at birth
FF varus compensated
how will this foot look in relaxed stance
- classic “flat foot”
- lateral toe sign (see 3rd & 4th toe sticking out)
- “false malleolus” - navicular bone drops down and in
FF varus compensated
why is this type of foot very problematic with dynamic function
person never really resupinates so getting excessive pronation in wrong phases of gait
* pronation thru late stance
* don’t have a rigid lever to push from
* tibia IR when knee needs to extend
* can see CIFR as a result
CIFR = compensatory internal femoral rotation
FF varus compensated
describe the callus pattern and why
2nd and 3rd MT heads
* peroneus longus isn’t able to stabilize 1st ray to ground during gait
pinch callus at medial hallux
* ABD FF
* inc toe out
common callus pattern for most hyperpronator foot types
what is the most destructive foot type
FF varus
FF varus compensated
what is compensatory internal femoral rotation (CIFR)
during midstance foot pron, knee and hip should be ext
* as knee ext –> tib ER
since tib is stuck in IR, get CIFR to get knee to ext
* femur IR produces relative ER at tibia which gives knee ext
FF varus compensated
how can metatarsalgia be a resulting pathology
d/t shearing forces at an unstable FF
FF varus compensated
how can plantar fasciitis be a resulting pathology
talus ant displaced, drops down and in resulting in excessive pronation which places inc stress on plantar fascia
FF varus compensated
how can achilles tendinitis be a resulting pathology
achilles attaches medial on calcaneus –> inc pull with excessive pronation
* achilles then working to decelerate pronation
FF varus compensated
how can hallux abducto valgus (HAV) be a resulting pathology
- peroneus longus not doing its job
- oblique forces of body mass
FF varus compensated
what are 4 PT interventions
control pronation
GS complex flexibility - address lack of DF
foot intrinsics
balance activities (NM control)
moving too much, want to control it
FF varus compensated
why would you want to address any lack of DF in this pt
pronation is often common compensation for a lack of DF
FF varus compensated
what orthotic and footwear would you prescribe in this foot type
biomechanical - medial FF post
* controlling excessive medial drop w compensatory pronation
motion control shoes – duo density midsole
what pt pop is uncompensated FF varus more common in
men
losers
FF varus UNcompensated
what does this foot type look like in relaxed stance
1st ray stays up
rigid foot type
FF varus UNcompensated
when doing a differential dx what is an important consideration if you suspect this foot type based on relaxed stance
this can be an antalgic compensation
* s/p bunionectomy
* turf toe
FF varus UNcompensated
what is the callus pattern and why
lateral border of foot
5th met head
more WBing on the lateral side
FF varus UNcompensated
what is the reason you see resulting pathologies
don’t have pronatory function to shift weight lateral to med
* don’t want to be walking/WBing on 5th
* poor shock absorption leading to prox sx
* c/o diffuse pain d/t WBing at a capsular end point
FF varus UNcompensated
what are 3 PT interventions
restore mobility - joint mobs
control GRFs
provide cushion - encouraging pron/mobility in kinetic chain (ankle, knee flex, hip IR)
FF varus UNcompensated
what orthotic and footwear would you prescribe
accommodative device
medial bias
footwear - cushion shoe
* shock absorption
* promote mobility
FF varus UNcompensated
what is a bias and why would we use this
bias = post made of softer material
since uncompensated, need post to be softer w more cushioning
* don’t want to have anything stiffening it bc already lacking motion
FF varus - needs medial posting
* material of post depends on if compensated or not
can FF valgus be compensated or uncompensated?
no
can think of it as uncompensated foot type bc more rigid and stiff
FF valgus
how will this foot type present in relaxed stance
supinatory foot type
typically high arch
FF valgus
what limits pronation on contact
pre-mature loading of 1st ray
FF valgus
what compensation for this foot type is seen in midstance and why
early re-supination
* need to get 2-5mets down to ground
* when sup pushes weight medial to lateral
problem is we don’t want weight to be lateral in midstance
FF valgus
what is the callus pattern and why
1st MT head
* premature load
5th MT head
* pivots to shift weight to contralateral foot
FF valgus
how can chronic lateral ankle sprains be a resulting pathology
WB-ing along lateral border of foot
* not difficult to continue motion laterally and roll ankle
* place stress on ATFL and CFL
FF valgus
how can peroneus longus tendinitis be a resulting pathology
overuse in stabilizing 1st ray
decelerating STJ supination (bc supinating early)
FF valgus
how can lateral / posterolateral knee pain be a resulting pathology
supination results in:
* varus
* recurvatum
structures loaded:
* biceps fem
* LCL / lateral joint capsule
* lateral gastroc
* ITB
* popliteus - IR tib / ER femur –> controls excessive ER of tibia associated w supination
FF valgus
how can pelvic girdle dysfunction be a resulting pathology
limited shock attenuation
forces transmitted proximally
think of FF valgus as uncompensated/hypopronatory foot type
FF valgus
what are 3 PT interventions
encourage pronation
control supination
NM re-ed
* adapt to uneven terrain
FF valgus
what orthotic and footwear would you prescribe
flexible biomechanical
* lateral FF post
* 1st ray cut out if rigid (accommodating)
footwear - cushion shoe
if 1st ray is flexible - biomechanical
cut out is an accommodative option if rigid
what is ankle equinus
lack of 10deg TC DF in STJN or supination
this is why we measure DF in supination to see ROM in TC
why is an ankle equinus deformity significant for gait mechanics
DF is what allows tibia to advance over foot
what are common impairments resulting in ankle equinus
joint restriction (TC)
ms length (GS complex)
ankle equinus
what are components to your assessment and how do you sus out muscle (soleus or gastroc) or joint restriction
prone DF
* knee flex - soleus
* knee ext - gastroc
any sx with overpressure?
* posterior sx = muscle
* anteiror sx = joint
end feels:
* capsular (joint)
* muscle
ankle equinus
what is a HUGE factor in if and how the pt compensates
MTJ mobility - flexible or rigid
ankle equinus
how will a stable vs flexible MTJ impact compensation seen
stable - early heel raise (vault)
flexible - compensate @ “little ankle”
* pronation thru oblique MTJ axis
ankle equinus
what are biomechanical adaptations w dec DF (3)
hip ER
genu recurvatum
dec step length
ankle equinus
dynamic function mechanics during gait look similar to what other foot type
FF varus
ankle equinus
what happens in midstance depending on if MTJ is stable or unstable
reach TC end range - tibia can’t advance over foot anymore
stable joint = vault
unstable = break thru MTJ axis & cont pronation
ankle equinus
what is the callus pattern and why
2nd and 3rd MT heads
hypermobile FF
ankle equinus
how can metatarsalgia be a resulting pathology
premature FF loading and prolong loading time
* inc pressures and fx
callus formation
ankle equinus
how can tib post tendinitis/tendinosis be a resulting pathology
trying to control excessive pron
ankle equinus
how can achilles tendinitis be a resulting pathology
excessive tension
working @ end ROM
ankle equinus
what is an important consideration when stretching GS complex
don’t let them turn foot out and break through joint axis into pronation
ankle equinus
what are 2 PT interventions
TC posterior joint mobs
GS complex stretching
ankle equinus
why should you be careful with the use of orthotic therapy in this pt pop
biomechancial orthotics often fail in these pt bc they lack DF
* take away their compensatory pronation thru MTJ –> makes it worse
before giving an orthotic, make sure have TC DF
ankle equinus
what orthotic might you consider and in what patient
heel lift
for temporary use in pts who are very reactive and uncomfortable
once they make gains w other interventions, take it out
