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Gait Exam: An active clinical case study, limitations, value and justification

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mart, Nov 30, 2009.

  1. Mart

    Mart Well-Known Member


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    This thread is a subtext to David Smith’s exploration of 1st ray. FncHL and plantar pressures thread @

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=40738

    The idea is to keep that thread nice and clean and allow diversion into nitty gritty of using observational video gait examination and cheap/fast/dirty clinical kinetic data for evidence to complement that. Also to consider limitations, value and justification for doing this.

    So here we can take that data apart. Currently this is an active patient, please feel free to ask for more info, I’ll provide it if I can.

    From a personal point of view I feel this is an opportunity to get some peer review of my own knowledge and approach. Recently there seems to have been an interest in other threads regarding using these tools but no attempt to I have seen to walk through a case history/ interpretation in detail.

    Perhaps I could steer the process a little just to keep it focused and break off into sub threads if warranted. I will try and keep the topic momentum going till exhaustion but limit its acceleration if possible so as not to get overburdened.

    The case is selected because of evidence of FncHL if diagnostic criterion is according to IPP (instant of peak pressure) but not IPF(force) (see thread above) or non weight-bearing passive ROM testing.

    Here’s cut and paste of my initial consult SOAP for background.

    54y old female.
    PMhx; hypothyroidism otherwise patient reports to be in good general health. PSHx nil.
    Medications thyroxine, patient reports no known drug allergies. Not seeking employment.

    S: left foot longstanding plantar heel pain and inner longitudinal arch pain, gradual onset 2004. Patient attributes this to effects of having started running at that timer. Primary care physician diagnosed chronic plantar fasciitis, had foot orthoses from sports therapist 2005 which had limited effect. Currently left greater than right plantar heel pain and bilateral dorsal midfoot pain, onset 8 months ago, no prior workup for this. Pain worse on rising from bed and rising after resting, condition worsens with increased activity and improves with rest. Wears crox @ home otherwise running shoes with foot orthoses. Avoids high impact exercise because of foot pain, walks track 3X per week 90 mins. Concurrent non specific episodic mild knee pain.

    O: posterior tibial pulse palpable, dorsalis pedis pulse palpable, digital hairs present.
    No signs of swelling, erythema, heat or skin lesions, no plantar lesion pattern. . Left foot but not right point of maximal tenderness at medial process of calcaneal tuberosity. Palpable dorsal mid tarsal joint osteophytosis right greater than left but no pain with passive motion. No evidence of functional hallux limitus with passive non weight bearing dorsiflexion MCJ @ metatarsal head followed by passive dorsiflexion of hallux. Range of motion of metatarso-phalangeal joint seems normal and unaffected with plantar flexion or dorsiflexion of 1st ray. 10 X single limb stance heel raise caused slight left side plantar heel pain and right foot dorsal metatarsal/cuboid pain. Impression of elevated ankle stiffness with passive ankle dorsiflexion. Existing rigid polypropylene foot orthoses vacuum formed from plaster bandage slipper cast have poor match to foot contour with foot relaxed and unloaded. Footwear fits well. Observing barefoot gait in hallway; unremarkable other than large bilateral abductory twist @ HO.

    A: most likely chronic plantar fasciosis of mechanical origin and mild midfoot joint overload/DJD.

    P: Optimise protection with existing mechanical options; use foot orthoses and running shoes constantly. Start stretching exercise regimen for soleus and gastocnemius – written handout supplied. Patient to make an appointment to review progress if not improving within two weeks for US and gait exam to evaluate further.

    On follow patient was not improved, Diagnostic ultrasound exam confirmed left side chronic plantar fasciitis (active inflammation) and right foot chronic plantar fasciosis (no evidence of neovascularisation). Gait exam was also done.

    To download anonymized gait data go to

    http://www.winnipegfootclinic.com/resourses.html

    If you open the excel spreadsheet it will give you organised kinetic data as indicated by the various fields.

    If you download the kinematic folder it contains an .html file which if you open will collate snapshots of key gait images which are synchronised for sag and frontal views.

    I thought to kick off to look at this, compare what I do, why and how others approach the same.
    My observational video gait examination template; I take from Chris Kirtley because I believe his assertion that it will pick up significant gait aberrations quickly and confidently in clinical setting. Here’s my note on this case most of which can be verified from the .html.

    Here’s cut and paste of my Observational video gait examination.

    The following simplified 10 point analysis was performed to select for key deviations from normal walking gait.

    1. Temporal spatial parameters were normal, age adjusted cadence, stride length, and velocity were within normal limits.
    2. Step lengths and times were symmetrical.
    3. On both sides the heel made first ground contact with the ankle joint in neural (0 degrees dorsiflexion).
    4. The knees were close to full extension at foot contact bilaterally. Stance side forefoot contact was a controlled decelerated ankle plantarflexion.
    5. Both knees flexed to around 20 degrees shortly after foot contact, extending again as the contralateral limb passed.
    6. Bilaterally knee extension was maintained throughout single limb support. Bilaterally heel rise began slightly AFTER the contralateral limb swung past (50% stance phase).
    7. Bilaterally the ankle dorsiflexed to about 10 degrees in late stance and then rapidly plantarflexed to about 15 degrees. The posterior surface of the heel EVERTED during late stance and propulsion, suggesting that the sub talar joint was NOT supinating normally with external rotation of the lower limb. Additionally there was abductory twist at heel off.
    8. Knee flexion was approximately 60-70 degrees during swing phase.
    9. There was no excessive forward or backward lean of the trunk during gait.
    10. There was no sign of abnormal frontal plane pelvic or trunk motion.
    On this basis there were deviations bilaterally at 6 and 7 from a normal expected walking gait pattern.

    I would regard this typical common finding for “late midstance pronator”

    I will gladly go back to original video and get more info but cannot provide the video files to protect patient identity.

    Any comments or queries on this so far?

    Cheers

    Martin
    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  2. Graham

    Graham RIP

    Sorry Martin,

    Where and what files do we download?

    Thx
     
  3. Martin,
    I have no idea what you are asking here.:bash:
     
  4. Mart

    Mart Well-Known Member


    Sorry should have added click on podarena icon, that allows access to data.

    To download anonymized gait data go to

    http://www.winnipegfootclinic.com/resourses.html

     
  5. Mart

    Mart Well-Known Member

    Hi Simon

    David Smith has speculated that FcnHL might be clinically detectable by measuring IPP and IPF at metatarsal head 1 and plantar digital area 1st toe. See his active thread on this).

    I have been monitoring this idea via a spreadsheet which calculates these data on everyone who I do a barefoot pressure measurement exam for past several months.

    I saw a patient recently who I think may give a bit of insight into this issue since she meets David’s criteria for FncHL but not the clinical test which many use as an index for FncHL.

    Before making any generalizations regarding my data for this patient the value of the interpretation I feel warrants some scrutiny.

    Concurrent with this are several recent threads requesting info on gait capture software and interpretation of data from these systems.

    To my knowledge no detailed analysis has been done on the forum before of this type of crude gait data which I think is quite commonly used clinically.

    This seems to provide a pretext to share an interpretation of an actively seen patient and see what that might amount to. I have made what I see a fundamental data, available to those interested and then hope to stimulate discussion regarding the value, limitations and justification for using this approach.

    Ultimately this may have some value in looking at David’s idea or perhaps not.
    To keep the discussion well focused it seems best to look at different parts sequentially. The starting point then is to look at what we might reasonably deduce from the walking gait data for this patient both generally and also possibly regarding the issues of vertical ground reaction force and qualitative kinematics.

    Hope that is clearer and also that you can now see where the data is.

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  6. Mart

    Mart Well-Known Member

    Hopefully those interested were able to download the various files.

    So . . . . . . what??

    Anyone want to add or take issue with the observational video gait examination report in my initial post?

    More equivocally I want to make the following observation from these shots taken from the videos.

    LF TSPS.jpg

    RF TSPS.jpg

    LF ILA CLOSEUP.jpg

    RF ILA CLOSEUP.jpg




    Given the similarity in step length and velocity (because there were no markers used this was taken from from location of the green arrow so represents ave velocity of that segment location for single step not that of COM of body)
    There is moderate evidence of greater inner longitudinal arch excursion of left foot than right foot just prior to HO.

    Any problems with this or what would others say?


    cheers

    Martin
    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  7. drdebrule

    drdebrule Active Member

    Martin,

    Thanks for the interesting post. I enjoyed looking at your data.

    The bigger question really is how does gait analysis change our treatment plan or how does it change our orthotic prescriptions? So for observations like great longitudinal arch excursion, functional hallux limitus, excessive pronation, absent arm swing on one side, poor symmetry etc. it all depends on what is important to you and what your think the treatment should be.

    There aren't enough studies out there yet to answer these questions fully, so the treatment protocols used from gait analysis results may vary widely from one physician to another. However, I believe patients will generally get better results with gait analysis and I think it is important to analyze how people walk. A patient with a foot flat strategy for heel strike for example might not improve if you only based their orthotic perscription on Root principles like their resting calcaneal stance position. On the other hand, it is also possible that our patients improve from a placebo effect. Perhaps patients are so much in awe of the state of the art gait analysis equimpment and fancy looking orthotics that they ar preconditioned to improve.

    I would like to see a double blinded ranomized future study comparing sham orthotics, over the counter orthotics, custom orthotics with a standard RX for all patients in study (let's say a 3 degree rearfoot post), and custom orthotics with individual prescriptions based on exam and gait analysis.

    Again, thank you for the interesting post.

    Dr. Mike DeBrule
     
  8. Mart

    Mart Well-Known Member

    Hi Mike

    thanks for your reply.

    I haven't had time to get going properly on this thread and have been sick this past week leaving me horribly backed up at the clinic so time is lacking right now.

    I agree with most of your sentiments but want to explore how those of us using these recording technologies interpret what they see. I think, as you mention, this in turn likely influences clinical decision making, not in isolation but in tandem with other clinical information. My sense like yours is a possible wide range of opinion regarding the value and justification for these "tests" and this is a good forum to fish around in. There are parameters which seem well established in the literature for gait abnormality but they seem to come from fairly extreme deviations such as neurological and traumatic disorders. The relatively small deviations which seem to be attributed to chronic MKS lower limb dysfunction are less accessible and I suspect that is mostly a factor of measurement error and immeasurable parameters which are confounding. I think that there are big problems in doing what you mentioned with RTCs in this area because of this.

    Anyhow, for what its worth I'll bait up some more hooks in a while for this thread and see what bites.

    One of the things which is reported in the literature is how unreliable kinematic gait exams are in terms of accurate reporting of what is observed. That is why I like to use Chris Kirtley's report template which I quoted earlier. I find it very reproducible and easy to unequivocally report with. It clearly pinpoints obvious basic dysfunction. I find it curious that, in Canada, most insurance companies demand a gait exam as prerequisite for covering custom foot orthoses yet to my knowledge there has been no attempt to define what this exam is supposed to amount to.

    Anyone else having similar concerns?

    Another thing is that I have seen mentioned on the arena is of clinicians being able to demonstrate the effect of FO on their patients from their observational video gait examination. I feel I must be missing something important because other than big changes seen with large leg length discrepancies, or effects of ankle foot orthoses or rocker soles which can be eyeballed I cant see what this will amount to and would love someone to open a thread with a convincing case study along the same lines as this one to share their approach. Any takers?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  9. Asher

    Asher Well-Known Member

    Hi Martin,

    I for one look forward to this thread developing and will take part once I have a bit more time on my hands. Have a great Christmas!

    Rebecca
     
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