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Patient with 'awkward' gait

Discussion in 'General Issues and Discussion Forum' started by Kent, Feb 21, 2008.

  1. Kent

    Kent Active Member

    Members do not see these Ads. Sign Up.
    I have a patient coming to see me tomorrow with what he describes as an awkward gait. Below is what he sent me in preparation.

    Sounds like at might be something neurological originating from the back.

    Any thoughts? Thanks in advance.

    Last edited: Feb 21, 2008
  2. Kent:

    Here is what I would do:

    1. Do a complete and thorough muscle strength evaluation of the both lower extremities.

    2. Do a thorough walking and running gait examanation (it would be cool if you could videotape and post his gait onto Podiatry Arena for all of us to see).

    3. Tell the patient he needs to have a consultation, nerve conduction velocity and EMG by a good neurologist. Emphasize to the patient how important this is.

    4. Suggest to the patient that an MRI scan of the lower vertebrae will help rule out lumbar/sacral vertebral radiculopathy.

    The patient appears to be exhibiting signs of foot drop. Here is a good article on foot drop for you and your patient.

    Please keep us informed of his findings and his progress.
  3. Kent

    Kent Active Member

    Thanks Kevin. I'll keep you posted. I'll see if I can figure out how to post some video footage of his walking and running gait.

  4. davidh

    davidh Podiatry Arena Veteran

    Hi Kent,
    Nothing to add to Kevin's post (he has has all the bases covered) except well done for thinking "outside the box".

    Many practitioners (not only Pods I have to say) would have fitted orthoses to this chap without doing the necessary workups first.

  5. Bruce Williams

    Bruce Williams Well-Known Member


    I agree with Kevin re: drop foot. It sounds from his hx that he may have been suffering from an anterior compartment syndrome brought on during exercise. I think he damaged the nerves serving the anterior muscle group and may now have a situation that could be irreversible.

    he will need a futher neuro consult for NCV. He may need an afo as well.

    Good luck.
  6. blinda

    blinda MVP

    Hi Kevin,

    Thanks for putting the foot drop article on here. This will be useful to refer to when I attend a multi disciplinary group meeting for one of my patients next week.

  7. drsarbes

    drsarbes Well-Known Member

    Hi Kent:

    Your patient sent you all this information PRIOR to his first visit?
    Runner, huh?

    We've all seen this, runners especially - who become rather "obsessed" with their "problem".

    Good luck - hopefully you can charge him by the hour because I'll guarantee you of one thing - you're going to spend A LOT of time with him.

  8. If you can treat a runner such as this and help him, where other doctors have failed, he will probably be sending 10 of his friends to you for treatment over the next few years.

    I was a competitive distance runner for over 25 years, and the runners that see me as patients greatly appreciate the fact that I "understand" their desire to compete and exercise by running. They often complain about non-sports-minded podiatrists that hey have seen previously that "put them off" by not empathizing with their concerns about not being able to train and compete due to their injury. I see runners that travel from as far as 100 miles away from my office to be treated for their injuries, not because there aren't any other podiatrists around Sacramento, but because I treat runners like I would like to be treated as an injured runner-patient.

    If you want to treat runners, then do a good job at it and more runners will show up at your doorstep. If you don't like treating runners, then send them to another podiatrist that does like treating them. Remember, one man's hobby and/or sport is often viewed as an obsession by others that don't understand the appeal of that hobby or sport.
    Last edited: Feb 22, 2008
  9. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    I assume the last post was directed at me.

    I respect your apparent clinical skills and impressive knowledge of biomechanics, but, you do seem to have a knack for misinterpreting me (at times).

    What I said was.."
    We've all seen this, runners especially - who become rather "obsessed" with their "problem" "

    This is directed at patients obsessed with a "problem" -not at runners, although it seems many are runner, but not necessarily.

    Patients who bring in list after list of symptoms; list after list of previous treatment; list after list of daily pain levels, diagrams (often color coded) of symptomatic area, etc....well, what would you call this? Obsessed? He was PROMPTED to get an MRI of his brain because of information he found on the internet!!!!!!

    There are many patients who have difficult problems , many chronic, some forcing them to change their life style, many unsuccessfully treated in the past. These patients don't routinely bring in (or send beforehand) mostly worthless information given in no particular order or following any particular historical questioning protocol.

    Frankly, I find this type of random, subjective, many times interpreted information more of a hinder. I find it much more useful to take my own history, from scratch, with a classic "I ASK, YOU ANSWER" formula.

    There is little in the clinical arena more worthwhile than a good medical history. Anything that prevents the examiners objectivity (like formulating a possible diagnosis before I even meet the patient) I find counterproductive.

    I'll stick to my first impression....... schedule extra time for this patient and don't be surprised if there is more than a little evidence of OCD.

  10. Kent

    Kent Active Member

    I saw the patient today. I'm still trying to figure out how I can post a video of his walking and running gait but below is the summary of his findings:

    • When problems started in 1992, felt right foot slapping flat on the ground without any coordination
    • Tingling sensation most of the time at the proximal 1/3 of the lateral right leg
    • No history of shin pain or feeling of swelling in the anterior leg that might indicate compartment syndrome
    • Often trips over foot (big toe) when walking in shoes and barefoot
    • No history of trauma to the leg (i.e. no direct damage to the common peroneal nerve)
    • CT scan of low back performed about 15 years ago showed no abnormality
    • Brain MRI WNL

    Everything else in his history is documented in my first post.

    Physical Examination:
    • Relaxed stance - low MLA and slight eversion of calcaneus
    • Ankle, STJ & MTJ ROM WNL BF
    • Moderate FF supinatus BF
    • Hallux limitus BF
    • Dermatological - Patches of red, scaley skin (skin scraping show no fungal infection). It looks like tinea but with a patchy distribution (not the typical moccasin distribution). He also has similar symptoms on the palmar surface of his hands. Being treated with a steroid cream.
    • Vascular examinations WNL BF
    • Neurological examinations - 1. Paraesthesia proximal 1/3 of lateral leg. 2. Muscle tests WNL BF - I checked and re-checked the muscle tests and I could not find any discernable difference between legs. 3. Slump test - mild discomfort through right gluteals/proximal posterior thigh.
    • Footwear assessment - Increased wear under right hallux.
    • Gait assessment - Right leg externally rotated in stance, cirumducts through swing, slight right hip hitching, reduced right ankle DF through swing (especially in terminal swing), moderate midstance pronation (rearfoot eversion and midfoot collapse) R>L.

    I've refered him to see a neurologist to get:
    1. MRI of lumbosacral spine
    2. Nerve conduction study
    3. EMG study

    I'll try to get the video posted ASAP.

  11. admin

    admin Administrator Staff Member

  12. drsarbes

    drsarbes Well-Known Member

    What exactly is his chief complaint (in 10 words or less)?
  13. Mark Egan

    Mark Egan Active Member

    Hi Kent ,

    Thanks for putting this case on for all to look over.

    Did he have a LLD?
    What was his glut/ core strength like?
    Did you try any form of padding strapping etc for him to try ? taking a leaf from Craig Payne I would try a firm heel lift under the R and soft under the L.
    How did the feet sound?
    What does he want to do? - function normally everyday? fun run distances? compete?

    Look forward ot hearing the results


  14. Bruce Williams

    Bruce Williams Well-Known Member


    I reviewed the videos and saw a few things as listed below:

    1) extended lesser toes throughout swing phase
    2) lateral trunk flexion towards the left to help initiate swing on right
    3) greater forward swing motion of left arm vs right
    4) AJE R possibly worse than left

    It could be that he has scarring at the fibular head that may involve the peroneal nerve. This can be related to AJE on this side adn failure of the fibula to superiorly translate during midstance.

    You state there is no discernible weakness R to L in muscle strength adn this leads me to possibly eliminate drop foot as a gait type.

    Everything I see screams FnHL and AJE. Get the neuro tests. Go see Dananberg's lectures in May in Australia adn learn his manipulation techniques, if you don't know them already.

    Accomodate the left by 3-6mm for LLD, and use a modified Low dye taping, start under the 5th met, around the heel and then back under the 1st met while holding the hallux extended. Use a 6mm double elliptical metapad to for the transverse metatarsal arch. Finally, consider a trinagular pad wider lateral and starting under teh 5th met adn ending at the 2nd met on the right foot, ie reverse morton's extension.

    See how he does with that for a few days and doe the manipulation with it as well if you can on both feet!

    Good luck!
  15. Ella Hurrell

    Ella Hurrell Active Member


    Forgive me for my apparent :wacko: state, but could you tell me what AJE stands for?!

    Thanks, Ella
  16. drsarbes

    drsarbes Well-Known Member

    Well, I too looked at the video, I'll stick with my original impression - OCD -

    Obsessive-Compulsive Disorder.

  17. Bruce Williams

    Bruce Williams Well-Known Member

    Ella and Steve;

    my apologies for the abbreviation. AJE = Ankle Joint Equinus.

    This gentleman does may or may not have OCD, and in my opinion he does have a mechanical gait related disorder that is most definitely contributing to his pain and dysfunction.

    I see patients similar to this weekly and the majority make great gains with a simple orthotic or brace related treatment plan. In-shoe pressure helps a lot too!

  18. pgcarter

    pgcarter Well-Known Member

    If he was a skier I think he probably could not glide relaxed on his right ski. I think there is an incomplete shift of centre of mass over the right foot, it happens better over his left, but he never really gets balanced well over his right. Can you do some balance/proprioceptive challenge exercises? I think you'll find a difference there....unless I'm imagining what I think I see....it is a slightly assymetric gait in terms of timing and body mass sway etc....in the coronal plane from behind is where I think I am seeing it
    regards Phill
  19. PodAus

    PodAus Active Member

    Hi Kent,

    When the Right Hamstring group is under stress/fatigue, do the symptoms increase significantly (loss of Right lower limb control?)

    Has there been any results from localised investigation into the Right hamstring origin attachment(s) (MRI), or Sciatic Nerve Conduction?

    Has there been any Hx of injury to the R Hamstrings or R Hip area?


  20. Kent

    Kent Active Member

    Hi all,

    I'll try to answer everyone's comments:

    Chief complaint - Often trips over his right foot

    No clinical evidence of a LLD - therefore I didn't see any need for hard/soft lifts. Core strength appears to be OK apart from the hitching. Sound - I couldn't detect any difference. Goals - reduce tripping over foot.

    There is no equinus - again I double checked this. There is significantly less ankle joint dorsiflexion on the right side (particularly in terminal swing). Just because I say there is no discernable weakness on the right compared to the left it doesn't mean there isn't. Maybe there is a 'subclinical' weakness which I couldn't pick up. He didn't have functional hallux limitus in my testing.

    Steve I too thought he might be a little OCD before I saw him but I don't think he is. Lots of runners provide detailed information. Does this mean they're all OCD??? He was promted to see me by a few friends saying he walked like he was injured all the time.

    In-shoe pressure analysis would be helpful but I don't have this at my practice.

    No complaints of hamstring injury. He has a constant pain above the ischial tuberosity and medial to the SIJ - could be piriformis syndrome/impingment as a result of an aberrant course of the sciatic nerve??? There hasn't been any imaging done of the proximal hamstrings. I didn't try stressing the hamstrings and re-checking symptoms. What are your thoughts with regards to this Paul?

    Hope this answers some of the questions raised.

    Last edited: Feb 26, 2008
  21. PodAus

    PodAus Active Member

    Hi Kent,

    I recognise this syndrome in association with sciatic nerve / ischial tuberosity injury - overuse (hamstring and/or adductor tightness), or traumatic (fall/ tear).

    The proximal origin of the hamstrings has intimate relationships with the inferior gluteal nerve and artery and the sciatic nerve - chronic localised stress /inflammation can increase with even relatively low grade exercise, such as jogging.

    An increase of symptoms, specifically a 'decrease or loss of control of the limb', after even several hundred metres may be obvious to the patient.

    Your thoughts in relation to the Patient presentation / History?


    Paul Dowie
  22. Kent

    Kent Active Member

    Hi Paul,

    No history of hamstring injury/tear. Pain is more proximal and medial to the ischial tuberosity. What are your thoughts on an atypical course of the sciatic nerve through piriformis? Could this explain his symptoms?


  23. Kent:

    My guess is that your patient does not have obsessive-compulsive disorder, does not have functional hallux limitus but rather has a sciatic nerve disorder that may or may not involve the piriformis muscle. Here are a couple of interesting articles with some patients that had foot drop with sciatic nerve involvement.


  24. nelsandr

    nelsandr Member

    Hi Kent,
    First of all, thank you for the good posting; this is obviously a good clinical challenge, and, as several have mentioned, is a good example of the need to sometimes go beyond convention in our observations and perspectives.

    I have worked with a considerable amount of sub-elite and elite runners in previous practice situations and have found that many (and including coaches) don't pay much attention to idiosyncratic gait mechanics thinking that the runner has been successful to this point due to what they have, so why mess with them. However, I think that your attention to the details of this individuals mechanics are exceptional.

    Having reviewed the postings, and watched your clips, I feel that the key to this individual's issues are in what you noted as the restriction in dorsiflexion, which is also observable in the good clips that you posted (although I prefer over ground ambulation). This would indicate that there is probably a restriction in the mortise joint, particularly in the ant. tib. fib. lig., but possibly more proximately toward the fibular head, which would result in soft tissue trauma and issues in the peroneal nerve that, with the impact over a long run could cause the symptoms similar to a foot drop.

    I would first palpate the ant. tib. fib. lig. to see if it is hypertrophied and painful and then test his dorsiflexion in weight bearing (i.e. in standing keeping heels down have him flex his knees resulting in max. dorsiflexion). I'll bet he'll feel a poke or restriction in the anterolateral ankle over the ant. tib. fib. lig. indicating that he is not getting joint play to accommodate the wider anterior aspect of the talus in the mortise. I would also check fibular mobility in anterior and posterior glide primarily distally but also proximately, and I would imagine that either or both will be either painful or restricted (isn't the distal location one of the top three places for neuro impingement/release in podiatric medicine?).

    General treatment for this would be soft tissue mobilization (X-fiber friction msg) over the ant. tib. fib. lig. and then ant/post mobilization of the mortise joint, then continued soleal stretch (would imagine that after the mobs. you would see a significant increase in WB dorsiflexion). Then continue by working on the Right sided weight shift increases, as pointed out by an earlier post, which requires an emphasis on hip extension, and also demands WB dorsiflexion.

    Good case, thanks,
    Andrew Nelson, PT
  25. Lawrence Bevan

    Lawrence Bevan Active Member

    I would agree with Bruce on the video interpretation. Fnhl/AJE bilaterally possible LLD, L shorter.

    Either 1 mobilise the affected joints and do the taping for a few days or 2 do a temporary orthotic for a few weeks,

    At the same time arrange an Orthopaedic/Neuro referral.

    "above all else do no harm" - I cant see whats wrong with this approach except if the pt is an out-and-out OCD and this condition is a product of an over-active imagination but its a bit early to send to Psychiatry???
  26. PodAus

    PodAus Active Member

    Hi Kent,

    Sciatic nerve conduction interference associated with piriformis syndrome and / or hamstring / adductor weakness. Not necessarily atypical anatomical course, but possible. How about a functional mechanical discrepancy around pelvis which is self-perpetuating with jogging?

    Why can the patient run uphill without symptoms, but not on flat? I bet you it is also worse (less control of limb over shorter distances) running downhill...(?)
  27. Kent

    Kent Active Member

    Thanks for your contributions. I'll be sure to keep everyone posted on the outcome of the consult/investigations with the neurologist.

  28. Frederick George

    Frederick George Active Member

    Since everyone seems to be arriving at the diagnosis of sciatica (the most common cause of foot drop, extensor weakness), what do we do with the patient after all the tests are inconclusive (commonly the case with sciatica)? Or what if we get an abnormal nerve conduction study? He's not bad enough for surgery.

    And meds won't help much.

    Do we send him to a psychiatrist because we can't (or some people don't seem to want to) help him?

    Perhaps something alternative is in order, like chiropractic, or prolotherapy. These alternatives exist just because of problems like this.

    By the way, from behind, walking on the treadmill, it looks to me like he is swaying to the left to avoid using his buttock muscles to lift the right side. If nothing else, heel lifts, or higher heeled shoes, will help him walk without tripping over his toes.


    Frederick George DPM
  29. drsarbes

    drsarbes Well-Known Member

    Dr. George:

    If you're not going to USE the results of a test then don't order it.

    Perhaps a few more hours of examination might turn something up!

    Sorry - I really don't mean to be sarcastic (sort of) but I saw this coming (the "I TOLD YOU SO" is a personality trait that my Ex taught me!)

  30. Frederick George

    Frederick George Active Member

    Dr. Sarbes

    We all order tests. We all decide, using that instrument between our ears, what tests to do or request. Then, again using that same instrument, we interpret them.

    What test would you recommend for "Obsessive Compulsive Disorder?"
    "I'll stick with my original impression - OCD - Obsessive-Compulsive Disorder."
    drsarbes - 25 Feb 2008

    As to your personal history with your ex-wife, I don't think we need to know.


  31. Kent

    Kent Active Member

    Hi Frederick,

    How do you propose a treatment like prolotherapy would work in this case? Where would you inject?

  32. Frederick George

    Frederick George Active Member

    Dear Kent

    I don't do prolotherapy, but since Dr. Hackett developed it many years ago, it has often been used to treat various problems in the back, including some of the causes of sciatica.

    You would need to find someone, usually a GP, who specialises in this form of treatment. There is a great deal written about prolotherapy, but for a start you can try: Getprolo.com


  33. lcp

    lcp Active Member

    hi kent, how has it been going with this patient? any further results in?
  34. drsarbes

    drsarbes Well-Known Member

    Hi Frederick:
    You sound a little defensive. Please, no need to be.
    All I meant was that if you decide BEFORE you order a test that the results are not going to change your Dx or Tx, then don't order it. That's all.

    "As to your personal history with your ex-wife, I don't think we need to know."

    You're choice...but it's pretty interesting. Would make a hell of a movie! haha
  35. drsarbes

    drsarbes Well-Known Member

    It's been several months.
    I'm very curious as to how this patient responded to further diagnostics and/or treatment.
  36. David Wedemeyer

    David Wedemeyer Well-Known Member

    I would like to add another possibility that has not yet been offered, although I believe that Dr. Kirby did cover this generally.

    Given the timing of the event, exertion induced loss of subjective strength during intense activity such as running, intermittent neuropathy in a sciatic distribution and constant sacroiliaic, buttock region/hamstring discomfort, I would rule out spinal stenosis vs. facet pathology/neuroforaminal encroachment in the lumbar spine. Either case could cause the radiculopathy that Dr. Kirby discussed.

    I have also seen patients with symptoms that are not entirely bilateral in early spinal stenosis. As they progress the typical neurologic intemittent claudication occurs bilaterally; cramping and loss of strength in the leg and lower extremity brought on by exertion and relieved by resting in the Valsalva position.

    He may also have a piriformis syndrome as was mentioned, in about 10% of the population (women > men) the sciatic nerve courses through the muscle belly. Any activity that increases abductory motion and extension in the hip and varus at the knee lights these people up.

    I would suggest referring him out to an orthopedic spinal specialist for a complete workup in addition to the neurologist. He should have both the spinal canal dimensions and the neural foramen evaluated for patency.

    I have a feeling that he is not revealing all of the relevant history to you. I treat runners and endurance athletes they are notorious for slowly giving out all of the details of their concern. I believe that this is because many exhibit a strong case of denial and minimization of symptoms because they do not want to have any of their activities precluded or modified. I would again ask him about his lower back history.

    On the other hand they present to the office loaded with material and seem to understand medical terminology greater than the average patient. This leads me to believe that they are doctor shopping in some cases for an answer that is acceptable to them, regardless of what is most appropriate for their case. This is what Dr. Sarbes is referring to and I find a lot of truth in this.

    I also agree is what Dr. Kirby points out and that is that only another runner (really any athlete) really appreciates what this activity means to their daily life. It IS their daily life and of the many doctors out there who claim to specialize in treating these certain athlete population, very few can truly commiserate their needs and feelings. Regardless of what the etiology of this gentleman’s complaint he wants a professional who “gets him” and can aid him in being able to continue running. I don’t think that this is impractical for most patients. I like to call it “the good side of selfish” because as a cycling enthusiast I understand that mindset.

    In this case though based on what I see in the gait videos I feel he has an antalgic gait favoring the right side. Definitely something is affecting his gait running and walking.

    He doesn’t appear to propulse off of the right great toe and instead circumducts the right foot at push-off and during early swing phase. Perhaps he has some first ray insuffiency or peroneal weaknees, I would suspect FHL looking at the films but Kent already ruled this out.

    Kent is his right foot Ficke angle increased? He appears to be toeing out on the right and I see this on the short leg side frequently in a functional LLI. Along with that the pelvic rotation will cause tightness and shortening of the gluteals, hamstrings and spasticity of the quadratus lumborum and deep spinals musculature thus altering normal hip motion during gait.

    Patients with this type of gait are typically right sided LBP, right LLI due to posterior nutation of the ilium and as time progresses they will lean away to the left and favor the right LE. This is I believe in line with PodAus’ suggestion of a functional mechanical discrepancy. I tend to agree.

    Lastly if this is a low back complaint then I must give large kudos to Dr. George for suggesting a course of chiropractic care if indicated (he also noted the left sway (which I believe may be antalgic in nature). Our professions could truly complement each other in my opinion. I cannot recall an early sciatic or LBP patient without objective weakness that I have treated over the years who did not have an excellent outcome with manipulation and PT.

    Please don’t beat me about the head for my views; I am only expressing a humble opinion and joining the fun….
  37. PodAus

    PodAus Active Member

    I would definitely be seeking sports chiropratic care and monitoring the functional outcome (change in running 'performance').

    How is this patient progressing?


    Paul Dowie
  38. Kent

    Kent Active Member

    Unfortunately still no word from this patient. I believe he is still waiting to see the neurologist. I'll be sure to update everyone as soon as I know something. Thanks for all the suggestions and comments so far.

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