Leg Length And Gait Cycle

Question 1

Short leg syndrome

Answer 1

Any condition in which an anatomical or functional leg length discrepancy results in

• sacral base unleveling (lower on the side of short leg)
• compensatory vertebral sidebending and rotation
• innominate rotations (usually anterior innominate rotation towards the short leg and posterior innominate rotation towards the long leg)

can be anatomical or functional

Question 2

Anatomical vs functional

Answer 2

Anatomical

• an actually length discrepancy in the individual bones themselves, cant be attributed to a somatic dysfunction.
• cant be fixed by OMM and needs surgical intervention or orthopedic inserts to correct

Functional

• a length discrepancy that is actually caused by a somatic dysfunction in the body else where.
• can be fixed by OMM and orthopedic inserts. Never needs surgery.

Question 3

All signs and symptoms of short leg syndrome

Answer 3

Sacral base unleveling (lower on short leg side)

Anterior innominate rotation on side of anatomic short leg

Posterior innominate rotation on the side of the anatomic long leg

Spinal curve will sidebend away from the short leg and rotate toward the long leg

Lumbosacral (Ferguson’s angle) will increase 2-3 degrees

Pelvis side-shifts toward the sides of the anatomical long leg

Neck/back/hip/knee/ankle pain

Asymmetric tightness of the psoas/glutei/piriformis/hamstrings on the anatomical short leg side

Internal rotation and pronation of the foot on the anatomical long leg side

(+/-) sciatica

Question 4

How to evaluate for a short leg syndrome

Answer 4

Check for uneven shoe wear and tear

Screen for scoliosis
- Sidebending occurs away from the anatomical short leg

Check for asymmetries

Check standing flexion test

Measure leg lengths while supine
- should not line up with standing flexion test

any sacral base unleveling (SUB) >5mm should be assumed to be short leg syndrome and needs imaging and further work up

Question 5

How do you measure leg lengths for anatomical short leg syndrome ?

Answer 5

Measure either from the ASIS or the superior aspect or the greater trochanter down to the inferior aspect of the medial malleolus with a tape measurer

A discrepancy of 6mm or greater (1/4 inch) = short leg syndrome on the shorter side

• must treat all somatic dysfunctions (especially pelvis/sacrum and thoracolumbar spine) first before measuring for anatomical short leg syndrome

Question 6

Treatment of short leg syndrome

Answer 6

1) always remove any somatic dysfunction that is present

2) if it still exists, order xrays or leg length scanograms (CT of supine leg lengths)
- consider heel lifts if > 5mm is present

• also should check medial history for trauma/radiation/tumor/etc.*

Question 7

How to get Sacral base unleveling measurements

Answer 7

1) Draw a reference line that is perpendicular on the film that goes straight down the sacral base
- in short leg syndrome, this line will usually not cross the pubic symphysis equally

2) get weight bearing lines by drawing a line vertically from the top of the femoral head and to the same level as the top of the reference line.
3) to get sacral base unleveling, find the groove where the sacral ala and superior articular process of the sacrum meet. Draw a horizontal line on both sides to the reference line, and crossing the weight baring lines
4) at the Point where the sacral base unleveling line crosses the weight baring line, draw a perpendicular line on both sides to the reference lines.
5) Measure the distance between the two lines in the previous step and divide by 2. This equals the true sacral base unleveling (SBU) distance
6) also check pelvic rotation by looking at the natal crease (top of the buttcrack). It should be along the reference line, if not then it is rotated

Question 8

HEILIG formula

Answer 8

Formula used to determine the size of the heel lift to use in an anatomical short leg syndrome

L = SBU / (D+C)

• L = heel lift
• SBU = amount of sacral base unleveling
• D = time present
  (1 = 1-10yrs; 11-30 yrs; 3 = 30+ yrs)
• C = amount of compensation
  (0 = sidebending only ; 1= rotation toward the convexity; 2 wedging/altered facets are present)

Question 9

How to measure if lift therapy is working

Answer 9

Reassess everything 2 weeks

Unstable (osteoporosis/acute pain/elderly/arthritis present) patient = must start with 1/16”

Stable patient = can start with 1/8” or whatever was calculated by HELIG formula

• DONT replace by more then 1/4” at a time*
• this will induce contralateral pelvic rotation

Maximum heel lift possible is 1/2”. If they need more then need to use anterior sole lift

Question 10

Side notes with leg lengths

Answer 10

If foot is pronated, use orthotic to correct possible pes planus

Lift must be used in each pair of shoes a patient wears

Start slow (an hour or 2 a day) dont start all day immediately (lots of back pain)

Question 11

One “gait cycle”

Answer 11

Heel strike to next heel strike of the same foot (2 steps)

• 60% = stand phase
• 40% = swing phase

Question 12

Stance phase subgroups

Answer 12

Initial double stance (10% of total gait cycle)

Single limb stance both right and left (40%)

Terminal double limb stance (10%)

the remaining 40% is in the swing phase

Question 13

Average stride length and cadence?

Answer 13

Stride length = 28-32 inches

Cadence = 90-120 steps per minute
- women tend to be faster by 6-9 steps since they are often walking next to taller males

average speed is 3 mph

Question 14

Stance phase sub phase names

Answer 14

Initial contact (first heel strike)

• ipsilateral innominate rotates posteriorly to allow hip flexion
• contralateral innominate rotates anteriorly to allow hip extension

Loading
- shock absorbed and weight bearing begins

Midstance
- limb/trunk stability is key

Terminal (final heel strike)
- Heel off leg is still contacting ground but is preparing to come off into swing phase

Pre-swing

• weight is released from stationary foot and limb is being positioned for swing
• thoracic vertebra rotates opposite swing foot
• lumbar vertebra rotates towards swing foot and side bends away from swing foot
• sacrum moves along the opposite oblique axis to the swing foot and locks the opposite SI joint up

Question 15

Swing phase sub phases

Answer 15

Initial swing (early swing) 
- preparing foot clearance from floor

Mid swing

• contralateral foot is in mid stance phase
• foot is cleared an advancement is being conducted

Terminal swing (late swing)

• preparing limb for stance phase
• complete limb advancement has occurred

Question 16

Why is waddling not efficient for gait?

Answer 16

It locks up both SI joints, so the sacrum cant rotate along the oblique axis well
- this causes the person to have to hike the hips to walk which is increased expenditure of energy and inefficient

Question 17

Typical abnormal gaits and typical reasons for them

Answer 17

Antalgic gait = pain/injury

• short stand on injured side
• long stand on healthy side

Ataxic = cerebellar dysfunction

• wide stance to maintain balance
• patient with sway towards the side of the injury
• CANNOT walk in tandem gaits

Choreiform = hyperkinetic involuntary motions from pathology (Huntington’s, Sydenham chorea)
- jerky erratic gaits that dont add up in stance times

Diplegic = cerebral palsy

• “scissoring” of the legs and narrow base
• tight adductor muscles and toe walks in addition (extensor spasms)

Hemiplegic = stroke/TIA

• extend lower extremity and flexed upper extremity
• swing phase involves internal rotation and circumduction of leg (no dorsiflexion possible)

Myopathic = waddling movement dysfunction
- trendelenburg and hyper lordosis patients

High stoppage/equine gait = neuropathic dysfunctions (specific nerves usually)
- foot drop is most common

Shuffling/Bradykinetic = Parkinson’s

Question 18

Huntington’s disease information

Answer 18

Caused by triplets in the Huntington gene on chromsome 4 short arm.
- “CAG” triplets in the huntin protein

Question 19

Goals of short leg treatment

Answer 19

Correction of postural defects

Alleviation or decreased pain

Shift of body weight

Overall realignment of biomechanics of MSK

must treat all somatic dysfunctions in the pelvis, sacrum, thoracolumbar spine, lower extremity.

Question 20

Ilizarov Procedure

Answer 20

Used to lengthen a signification shorter limb

Break the limb and attach the external fixator that is adjusted up to 4 times a day lengthening the fracture by 1mm a day

not really used anymore since its super painful

Question 21

8 phases of the walking gait and the functions

Answer 21

1) initial heel strike
- establish contact with leading foot
- BEGINS STANCE

2) loading response/flat foot
- shock absorption
- BEGINS WEIGHT-BEARING

3) Mid-stance
- Limb & trunk stability
- progression over stationary

4) heel lift/off (terminal stance)
- progression past stationary foot
- prepare for swing

5) pre-swing/ toe-off
- weight release from stationary foot
- position limb for swing

6) Initial swing/ early swing
- prepare for foot clearance
- advance foot from trailing position

7) mid-swing
- foot clearance
- limb advancement

8) Terminal swing/ late swing
- prepare for stance
- complete limb advancement

Question 22

Requirements for normal gait

Answer 22

Stability in stance

Foot clearance in swing

Prepare for initial contact

Adequate step length

Energy conservation

Question 23

what motions are required to properly coordinate foot clearance in a swing of the entire limb

Answer 23

Ankle dorsiflexion

Knee flexion

Hip flexion

also requires motion to be allowed in the sacrum and innominates

Question 24

What are the results of step length being too short and too long?

Answer 24

Too short
- minimal progress for amount of energy used (not efficient)

Too long

• lose balance
• strain ligaments and muscles

Question 25

How does lumbar and sacrum move during pressing/toe off phase?

(Assume right leg is toe off leg)

Answer 25

Pressing/toe off:

1) thoracic:
- rotates opposite toe-off leg

2) lumbar:
- rotates towards toe-off leg
- side-bends opposite toe-off leg

3) sacrum:
- moves left along a left oblique axis
- left SI joint bears weight and allows right side to move
- sacrum rotates opposite lumbar rotation

Question 26

How does lumbar and sacrum move during initial swing phase?

Assume right leg is initial swing phase leg

Answer 26

Right leg/innominate:

• hamstrings tense up
• slight posterior innominate rotation
• weight swings to left side

Sacrum:
- rotates forward along the left oblique axis

Question 27

How does the pelvis move in inital contact phase of gait?

Answer 27

Foot that is coming out of swing to be in stance (anterior leg):

• ipsilateral innominate rotates posteriorly (leg can swing forward and hip flexion occurs)
• deep sacral sulci occurs here

Foot that is coming out of stance phase (posterior leg):
- ipsilateral innominate rotates anteriorly (leg can swing backwards and hip extension occurs)

Question 28

What side during the gait cycle always has a deep sacral sulci?

Answer 28

The side where weight is on (side that is currently in stance phase)

Question 29

What happens to the trunk and pelvis once mid stance phase occurs?

Answer 29

Everything begins to reverse itself

Question 30

How does weight bearing and gait cycle correlate with sacral movement?

Answer 30

Which ever side has the stance/weight bearing leg = ipsilateral on ipsilateral sacral torsion.

Question 31

Pathological gait

Answer 31

Abnormal gait cycle that is caused by some sort of pathology

Question 32

Most common bacterial and viral causes of Guillain-Barré syndrome (GBS)?

Answer 32

Bacterial = campylobacter jejuni

Viral = influenza/CMV

Question 33

Antalgic gait specifics

Answer 33

Typically seen in patients with injured bones/joints in lower extremities

Results in:

• shorted stance phase on affected leg
• lengthening stance phase on healthy leg (contralateral)

Question 34

Ataxic gait specifics

Answer 34

Almost exclusively seen in cerebellar dysfunction/injury

Results in:

• wide stance for gait cycle
• patient will sway towards the side of the injury
• “intoxicated patient taking a soberity test”

Question 35

Diplegic gait specifics

Answer 35

Typically seen in patients with cerebral palsy

Results in:

• extensor spasms/toe walking throughout gait cycle
• narrow base throughout gait cycle = drags legs/feet
• tonically tight adductor muscles = crosses legs naturally during gait cycle (“Scissoring”)

Question 36

Hemiplegic or spastic gaits

Answer 36

Typically seen in stroke patients

Results in:

• flexed upper extremity on ipsilateral side
• extended lower extremity on ipsilateral side
• circumduction and internal rotation of ipsilateral leg during swing phase of gait cycle

Question 37

Myopathic gait specifics

Answer 37

Results usually from gluteus Maximus or medius weakness

Results in:

• trendelenburg effect (contralateral hip tilts down during stance phase)
• hyperloridosis in lumbar region of neutral posture

Question 38

Neuropathic gait

Answer 38

Also called high steppage/equine gait)
most common inherited neurologic disorder as well

Usually seen in patients with common perineal nerve injuries/impingement

Results in:

• tonic hip/knee flexion
• foot drop during swing phase