Case History: Pronated Gait and Leg Shortages

 

 Patient:  XXXXXXXX  XXXXXXX
 

Subjective Complaints:

38 Year Old Male who presents with Lumbar (L3-L5) Pain which symptoms are described as a sharp localized pain in the low back with periodic buttox pain.   There are general fatigue symproms in the body which occur on a daily basis.   The more he walks, and stands, the greater the discomfort.

 

Past Medical History: Unremarkable

 

Past Surgical History:  None except for oral dental surgery

 

Occupational History:  Works in a inventory supply warehouse 8 hours a day.   Symptoms seem to intensify around 3 PM and last through the evening.

 



Objective Findings:
Examination is performed by evaluating the plane of the deformities.

 

Weight 230 pounds     BP 135/85   Pulse 82  

 

Orthopedic Examination

Stance Examination:

Frontal Plane

• Knee position medially deviated (moderate) Coxa Vara Genu Valgum)
• There is a Left Pelvic Drop on palpation suggesting a possible leg shortage
• There is palpable pain in the lower lumbar quadrant which seems more intense ion the right side.  
• Both feet are fully pronated

Lateral Plane

• The knees appear hyperextended (Genu Recuvatum) bilaterally
• The lumbar spine is in lordosis
• There is moderate abdominal distension with possible abdominal hernia and no protrusion or palpable viscera.

Transverse Plane

• There is a 12 degree abducted midline position equally
• The rearfoot is everted bilaterally

Dynamic Examination: 

• There appears to be a right shoulder drop
• The patients gait is pronated
• There is extensive transverse internal limb rotation from heel contact through midstance

Structural Examination:

• Patient has moderate Hallux Abductus with 1st Ray hypermobility
• The 5th Ray is also hypermobile bilaterally
• There is moderate Tibial Varum bilateral
• Range of motion of knee and hips are symmetrical with no crepitation

Range of Motion:

• Hypermobility of foot joints
• Same for soft tissues

Gait Examination:

• Suggest excessive pronatory pathomechanics of both feet
• Patient has an antalgic Gait favoring the left leg 

3D Weight Bearing Kinematic Examination using 3DO Imaging:

•  Static Analysis reveals weight shifting to the right limb suggesting left leg shortage.   The weight distribution of the left leg is 40% and 60% for the right leg.  There is high impact loading in the plantar calcaneal areas R>L.  There is also high impact loading on plantar 2,3,4 MPJ bilateral.   1st and 5th MPJ areas fail to load proper percentage of weight.
• Dynamic Analysis reveals heel contact everted on right more than left.   Mass migration fails to load on the 1st ray and instead migrates through the lesser metatarsals.   The 1st and 5th rays are hypermobile bilaterally.

Assessment - Diagnosis: Key is to list Diagnosis based on Treatment for best payment.    Send in Outcome Measurement Report with billing for objective justification.

1. Pes Planus Bilateral
2. Metatarsalgia with Metatarsal Depression 2,3,4 bilateral
3. Antalgic Gait
4. 7 degress Midtarsal Joint Varus Left  and 9 degrees Right
5. Hypermobile 1st Ray bilateral
6. Tibial Varum
7. Hamstring Equinus
8. Coxa Vara Genu Valgum
9. Unilateral Short Leg Syndrome Left
10. Lumbar Disc Syndrome L 4-5
11. Lumbar Lordosis 

Treatment Plan:

1. 3D Weight Bearing Kinematic Analysis
2. Gait Analysis
3. Video Analysis
4. Casting

 

Prognosis: 

• Excellent - Treatment of biomechanical etilogy will provide a restabilization of pathomechanical diseases in this patient and prevent surgery of the spine.
• See Outcome Measurement report (attached)

 

Followup:

• Recommend 6 month followup analysis to evaluate progress and provide adjuetment to current biomechanical program. 

 

Discussion:

 

Hypermobile Pes Planus feet with associated midtarsal joint varus pose a significant load bearing problem for upper extremity joints as this foot creates a significant amount of internal leg rotation as a result of pronatory movement of the feet.    Treating and stabilizing the biomechanical motion is critical as well as elevating the short leg.   Failure to treat the mechanical disease leaves the patient vunerable to surgery and toxic oral anti-inflammatory treatments which will not treat the cause of disease.

 

 

 

 

 

Hypermobile versus Rigid Pathomechanics

 

Hypermobile versus Rigid deformities are functionally opposed relative to the dynamics of biomechanical and ergonomic disease.   In general, Hypermobile feet have too much motion and Rigid feet have restricted motion. 

 

The foot has two fundamental functions;

1. Act as a shock absorber along with the knees as the body impacts the floor
2. When Midstance begins (forefoot contact), the foot changes in a millisecond into a Stabilizer through effective Wedge Joint Locking of the Rearfoot, (Sub Talar Joint) against the Midfoot, (Midtarsal Joints and 1st Ray (Navicular, Medial Cuniform, 1st Metatarsal, and Hallux).  This is assisted from reactive ground force through the plantar foot,  Failure of proper locking, leaves the foot unstable and there is resultant excessive limb rotation (Midstance through Propulsion).    

The Custom Bio-Engineered Devices must be able to adequately position rearfoot loading which maximizes Sub Talar Joint function and wedge locking of the midtarsal joints in a precise millisecond of time while enable the 1st Ray to properly load during midstance.  At the same time,  allow the digits and hallux to grasp and propel weight.

The most common type seen in clinical practice is the hypermobile foot and limb syndrome.

 

This condition presents itself with a foot with excessive motion and a limb with excessive motion at articular joint surfaces.   The patient presents with excessive mobility of joints of the feet and relative transfer of abnormal pronatory range of motion in the form of excessive internal leg rotation from he'll contact into mid stance.  

 

These patients will present with a unstable he'll contact with rapid midtarsal joint subluxation and pronation secondary to lack of midtarsal joint locking in addition to hypermobility of the first ray.  

 

These patients will also demonstrate apropulsive toe off due to lack of plantarflexion of the first ray from mid stance into propulsion due to hypermobility of joints as well as lack of extrinsic pull of the peroneus longus and assistance of the posterior tibial tendons.

 

In general, hypermobile feet translate into excessive internal limb rotation creating excessive pathomechanical disease in the knees, hip, and spine due to excessive pelvic rotation.  When the normal axis of motion is disturbed, then the joint(s) must work off their normal axis and then injury and disease sets in over time (Wolf's Law). 
 

Objective assessment only goes so far, and it is necessary to get finite close kinetic chain evaluation through the intervention of 3-D weight-bearing kinematic imaging which evaluates (7) area of important areas of load bearing mechanics;

1. Mass Displacement Analysis
2. Body Balance in all 3 planes
3. Pressure Load (Linear and Sheer Pressure)
4. Motion Analysis (Velocity)
5. Symmetry
6. Gait Analysis
7. 3D Plantar Foot Geometry

How we see Biomechanical Anatomy (Transverse Plane)

4 Anatomical Quadrants with different and unique functions

 

 

Center Point of Balance in all three body planes

 

 

Foot Types

 

 

Midtarsal Joint Varus versus Valgus Pathomechanics (Frontal Plane)

 

Midtarsal Joint Varus is the most common biomechanical disorder.

 

 

 

Midtarsal Joint Varus

Non Weight Bearing = Forefoot Inverted - Weight Bearing = Everted Rearfoot

This deformity can be present in a Pes Planus (flatfoot) or a Hypermobile Pes Cavus (high arch off weight bearing and low arch on weight bearing).

 

 

Transverse Plane - Midtarsal Joint Axis

(Oblique and Longitudinal)

 

 

 

 

 

Lateral Plane Midtarsal Joint Axis

(Oblique and Longitudinal)



 

 

Hypermobile 1st Ray (Navicular - Medial Cuniform - 1st Metatarsal - Hallux)

Non Weight Bearing = Forefoot Normal - Weight Bearing = Everted Rearfoot

 

The difference is that in weight bearing, the 1st Ray's is excessively hypermobile and fails to plantarflex during midstance leaving the lesser metatarsals vunerable to increased impact loading.  

 

 

 

 

Both the Midtarsal Joint Varus and Hypermobile 1st Ray deformities create unstable and excessive transverse plane limb rotation leading to knee, hip and spinal pain.   Control is critical and requires Dynamic 3D assessment.

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Midtarsal Joint Valgus

Non-Weight Bearing = Forefoot Everted - Weight Bearing = Inverted Rearfoot

Commonly seen with Cavus and Rigid Plantarflexed 1st Ray deformities

 

  

 

Subtalar Pathomechanics

The articulation between the Talus and Calcaneous makes up the Sub Talar Joint.    It is a trimotion joint and is responsible for wedge joint locking of the Midtarsal Joints during midstance.   It's function is affected by many factors including Lateral Plane Equinus influences. 

 

The more the oblique the articulation, the more unstable and pronated influences will effect the rearfoot and midfoot.





 

 

 

STJ Range of Motion - (example)

 

 

Lateral Plane Influences (Equinus)

 

 

 

 

General Commments on Body Plane Pathomechanics

• Think 3D - Everything occurs in all three body planes
• Understand the influences of extrinsic and intrinsic musculoskeletal influences 

 

Equinus and its effect on Pathomechanics

• Equinus usually involves the Gastrocnemius - Soleus - Hamstrings
• Equinus is a major deforming force on the body, (Spine - Pelvis - Hip - Knee - Foot).   It accelerates the velocity of pronation resulting from hypermobility due to the forward displacement of mass. 
• It causes prematire forefoot loading and unlocking of the Subtalar and Midtarsal Joints not to mention the 1st Ray.   .
• It affects spinal, knee and hip function dramatically.
• It is a major component to Spinal Disease and pain
• It is a component to acceleration of knee instability and disease 

 



 

 

Structural (Bone/Osseous) Disease and its effects on Body Pathomechanics

 

• Leg Shortages (Pelvis fromntal Plane)
• Tibial Torsion (Transverse Plane)
• Tibial Varum (Frontal Plane)
• Acetabular to Femoral Shaft Deviations - Coxa Vara / Coxa Valgum - (Frontal Plane)
• Calcaneal Varum (Frontal Plane)
• 1st Ray (Metatarsus Primus Varus) - Transverse Plane
• 1st MPJ Articular Adaption (Vallux Abducto Valgus)  Transverse and Frontal Plane
•  Hammertoes
• Calcaneal Exostosis (Heel Spur) - Lateral Plane