Interpreting gait, late swing abnormality

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Hi

I am canvassing some opinions regarding a current case.

Short report:

Obese 49 yr old, hx left PHP worsened since being fitted with rigid FO approx 6 months ago. Point tenderness medial heel, but not plantar heel. Diagnostic ultrasound inconclusive for proximal plantar fasciititis. Restricted ankle ROM 0 deg Dflexion, hard end point, genu valgum, FPI -1. Unusual gait; late swing unusual degree of supination, this occurring after ground clearance and past contralateral limb. Heel contact very inverted with very rapid pronation into FF loading. FF loads initially at 1st MTH.

My impression is most likely irritation of calcaneal nerve from FO at peak of resistance to pronatory motion (rigid polypropylene FO moderately high heel counter.). Pt reports FO made originally for lateral ankle pain from slipper cast, unsure of any Dx from provider of these FOs. I have asker her to stop FO use for a week and review effect of this.

Help please with interpreting gait. My impression is of recruitment of Tib Post, EHL to try and increase internal DF moment at ankle during swing causing excessive late swing supination, question is though why this would occur. If it were earlier in swing to improve foot clearance or if Tib Ant were weak this would be reasonable compensation but this seems not to be case.

I have uploaded a file with short video clip, gait parameters with point breakdown and detailed SOAP if anyone is interested to check it out at URL below.

http://www.bestsharing.com/files/ms00110052/Patient details.rar.html

Thoughts and questions very welcomed.

BTW thanks to everyone who contributed to the question regarding the “Lunge Test” late last year, brilliant!

Cheers


Martin
Winnipeg

 

Her left lower extremity appears to have increased genu valgum compared to the right. Both pant legs are rolled up to the same height which accentuates the genu valgum effect. This valgum/rolled up pant leg arrangement on the left lower extremity may be causing the femur/tibia to abduct in midswing to avoid the other knee/rollled up pants leg. It doesn't appear to me to be STJ supination causing this motion, but rather rapid leg abduction in early swing and rapid leg adduction during late swing with fairly normal STJ kinematics. Also, it appears as if she is avoiding heel contact on the left while walking on your hard floor, possibly in compensation for painful left plantar heel. She is obviously using her ankle joint plantarflexors (probably gastroc-soleus) in late swing to avoid heel contact which may also be contributing to the odd appearance of her left leg swing phase motions. It would be interesting to see if this leg abduction-adduction motion during swing on the left diminished when she walked in shorts and on a softer surface-such as a carpeted floor.

 

Hi Kevin

Thanks for your thoughts, everything you mention makes sense and although she did not CO PHP during the recording, given the concern regarding the other factors warrants another revised exam anyway removing those elements, I'll have another look when she returns to see me and post later for anyone interested.

cheers

Martin

 

.avi without pants!

Hi Kevin

I have uploaded another .avi file, this showing same views but with shorts removing possible effect of rolled up pants. It had occured to me that gait would be effected by needing to abduct these obese thighs for swing clearance, however when I look at this frame by frame the abnormal motion seems to occur after the limb has passed the mid point and cleared contralateral one. I checked with the lady and she confirmed that there was no pain during this exam, actually feeling more comfortable than wearing shoes with FOs. Also from the video it seems that she is making left side forefoot contact rather than heel contact, when I look at the FScan data (inshoe, removing effect of tiled flooring) this in definately not the case and heel contact is normal but forefoot loading initially 1st metatarsal head rather than 5th (left side only). This is consistent with your notion of avoiding heel contact to avoid pain but not with the reported experience. It would interesting to video her wearing the running shoes and see if that altered things.

so I am still scratching my head, if you have a moment, please have a look at the new file uploaded at

http://www.bestsharing.com/files/ms00111118/edited #2.avi.html


thanks for your time and expert opinion, I have no one to bounce this around with up here so really appreciate this

cheers

Martin

 

Martin:

Your link above to bestsharing.com did not work. Perhaps you can make sure the link works properly for me and the rest of the members of Podiatry arena since when the URL has a space within its characters, it separates out the segment of the URL that follows the space (i.e. #2.avi.html is not part of the URL the way you sent it to Podiatry Arena).

 

Ditto on that one, I have tried the link a few times and it comes up as an invalid file...

 

There seems to have been a problem with the server, it was a free service so I guess I can't complain, I have uploaded the revised video to a different site, I did test this and it worked fine so please try again

http://www.savefile.com/files/9642552

cheers

Martin

 

She is definitely striking forefoot first on the left foot in the few steps you have provided us. However, she doesn't seem to have a true steppage type gait pattern caused by weak ankle joint dorsiflexors where you would expect to see increased hip flexion and knee flexion during swing to clear the resultant plantarflexed foot and prevent tripping.

It appears to be some form of gait compensation where she is recruiting the gastroc-soleus in late swing to avoid heel contact, for some reason. Maybe she has a short gastroc-soleus and/or weak extensors. However, I would put my money on the fact that she has probably learned to walk as a forefoot striker on the left foot on hard surfaces without shoes on to avoid heel pain and she is continuing to do so even though she may not have heel pain currently (i.e. she is afraid to have her heel hit the ground barefoot and have the heel pain return).

It is interesting that removal of the rolled up pants at the knee level has improved her odd tibial abduction-adduction motion during swing, since I hardly see it now. However, her genu valgum and large thighs persist which is likely causing the remainder of this odd tibial motion during swing.

 

some further thoughts

Hi Kevin

Thanks for your helpful comments. It will be interesting to see if this gait changes with time.

I was hunting around for some ideas yesterday and came across a study of difference between barefoot and shod running biomechanics. Although this deals with a different gait style, particularly with difference in knee flexion at foot contact, given the large contact forces involved because of obesity I thought there might be some relevant parallels in comparing possible similar compensations.

I am wondering if anyone is noticing this pattern in their obese patients particularly differences between barefoot and shod gait irrespective of complaints of PHP

I intend to have a look at this lady’s shod gait for comparison when she returns to see me next week and I’ll post the video for any one interested


cheers

Martin


here’s the relevant extract;

In barefoot running, placement of the foot is significantly more horizontal than in the shod condition: This flatter foot placement
results from a significantly larger plantar flexion of the
ankle and a significantly more vertical position of the
shank in the barefoot condition. The latter is caused by
a larger knee flexion because there is no difference in
thigh orientation at touchdown between barefoot and
shod running. It is interesting to note that this more horizontal foot
placement is prepared well before touchdown. In the
barefoot condition, the ankle is already significantly
more plantar flexed at 0.03 s before touchdown and the
knee becomes significantly more flexed from 0.02 s before
touchdown.

The flatter foot placement in barefoot running could
be explained by another functional demand. In previous
research it was shown that at first ground contact the
heel pad is suddenly deformed to a physiological maximum
when running barefooted (De Clercq et al., 1994).
The deformation of the fatty heel tissue is proportional to
the local stress acting on the plantar side of the bare heel.
This means that for a given vertical impact force * the
F;* being non-different in barefoot/shod*, the local
pressure on the heel can be reduced by adopting a flatter
foot placement, through which initial ground contact
covers a larger plantar area. In this way overloading of
the heel could be prevented. Indeed, in the barefoot
running condition the maximal local pressure underneath
the heel correlates negatively with the sole angle at
touchdown. The more horizontal the foot, the smaller the maximal pressure acting on the heel.

It is also remarkable that the horizontal component of
the touchdown velocity is significantly smaller in barefoot
running. As sensation of mechanical inputs and pain is well established in
the foot sole (Bojsen-Moller and Jorgensen, 1991) it is
assumed that runners adopt a flatter foot placement in
barefoot running in an attempt to limit the local pressure.


Journal of Biomechanics 33 (2000) 269}278
Biomechanical analysis of the stance phase during
barefoot and shod running
Brigit De Witt, Dirk De Clercq, Peter Aerts"