Hi all just thought I'd post this case study for fun, useful study and maybe get some interesting debate going.
This lady had previously seen her GP and ref'd to other MSK specialists but had so far had no diagnosis or effective treatment. After evaluation I referred back to her GP. The attached pelvic X- ray was taken after re-referral to GP. The letter to the GP pretty much covers the case History, patient presentation, patient expectations, clinical findings, diagnoses and recommendations and initial intervention by myself.
Mrs C later reported by phone that further investigation by MSK /orthopods was scheduled and that she felt her gait and posture was much improved by the heel lift and mobs and had also reduced painful symptoms.
(Letter to GP)
Dear Dr J
Mrs C who is 74 years old has attended my clinic today complaining of lateral thigh pain and anterior shank pain and requesting an assessment of gait and posture with a view to improving and awkward limping gait and resolving pain, although pain appeared to be a secondary issue to the gait progression.
No meds, no significant medical history admitted to except general OA.
With regards to pain there seems to be several separate pathologies:
1) muscular stress, i.e. ilio tibial band and anterior Tibialis, caused by the compensations required to stabilize the limping gait.
2) Extraordinary pelvic position that requires further investigation
3) Loss of right hip Range of motion (RoM) and associated pain in the groin and knee indicates the possibility of arthritis of right Hip.
4) Loss of right hip flexion RoM and weakness in hip flexors.
1) Equinus ankles and much reduced internal / external RoM of right hip result in
excessive stabilizing strain on ITB at left swing thru. The equinus ankle and
inability to flex right hip result in overuse strain of Ant Tib muscle in order to
clear forefoot of the ground during right swing phase.
2) (and including 4) The pelvis is rotated to the right in the transverse plane so
with feet and knees facing forward the ASIS faces 30dgs to the right. The right
innominate ilium (pelvic half) appears to be smaller than the left and this may
account for some of the apparent pelvic rotation. (NB the right and left GT
appear to be aligned in the same transverse plane.) The reduction in ilium size
may also account for some of the hip flexor weakness since there would be a
reduction in moment arm (effective lever) for the Rectus femoris muscle about
the joint and the pulley lever action of ilio-psoas is reduced. However Mrs
C reports that the weakness only started or was noticeable from about
2 years ago. Therefore with the abnormal pelvic rotation in at least two planes
there may be some narrowing of the vertebral lumen (L234) and compression
of the femoral nerve. The right iliac spine and Greater Trochanter are lower than left by about 30mm and measuring from GT to lateral malleolus there is
20mm shortness in the right leg.
3) Hip RoMs are 5dg internal and external rotation, passive and active, Hip
flexion is 80dgs passive and less than 20dgs active. Passive flexion causes
pain. Mrs C reports groin pain and knee pain that is intermittent.
In walking gait Mrs C rocks from side to side and drops onto the right foot
both as compensation for the short leg and also for weak hip abductors. At present I have fitted a 13mm triple density extended heel lift in the shoe beveled to 4mm at the fore foot / MPJs. I have also mobilised the ankle joints to enable greater range of motion in dorsiflexion. These simple measures have greatly improved the gait progression. That is, the foot clears the ground more easily, the right leg is effectively the same length as the left and the joint mobilisation releases muscle tensions and improves strength in the hip abductors. She was quite pleased with these results and she may find this sufficient for her needs.
However, Dr J, I have referred Mrs C back to you for further
investigation of the pelvic position, right hip and lumbar spine / sacro-iliac condition, query arthritis. I feel it is important to establish the pathology that has led to the functional gait problems and recognize the actual anatomy here before proceeding with any extensive therapy.
Regards Dave Smith