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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.
Quote:
• Distance runner for 22+ years until 1995 – switched fully to road cycling Easter 1995
• Best times – 10km 35:38, 5km 16:55, ½ marathon 1h 16min, sub 3 hour marathons
• Mid 1980’s did some serious triathlons – 1988 went back to just running.
• Mid 1980’s had Morton’s Neuroma? Between a couple of metatarsals of right foot – took quite a while to go away.
• 1992 began to experience strange problem with right leg – loss of coordination when running, leg slamming straight down instead of normal stride, leg also rotating outwards involuntarily when this occurred – at first this would occur at about 25km point in a long training run – over the next 18 months the problem gradually came on earlier until eventually I could not run 5 km without this occurring.
• I could temporarily relieve this problem during a run by doing a brief straight leg stretch with the affected leg, which allowed maybe another 5 minutes running before it struck again – this few minutes relief would usually become shorter until the stretch would not be effective for more than 100 metres or so.
• Probably worth noting that I could run uphill (as in a King of the Mountain type run) without this problem occurring – a more bent over posture running uphill.
• Last year I found a somewhat similar description to my problem on the internet – quoted below (ignore the 1600 metre distance bit) – which prompted me to try to pursue the issue again – I actually had an MRI of my brain last year – nothing found to associate with my leg problem.
“When running tempos or races longer than 1600 meters on flat hard surfaces, my right leg will give out on me. It feels like pressure is building up to the point where it has no firing power and no control, and it will slam straight down and I will land flat footed. Also, I will not be breathing hard when this problem occurs, which makes it even more frustrating.”
• 1992 – 1993 Consulted physio, orthopaedic surgeon (lots of scans etc) and neurologist (was supposed to get nerve conduction studies done, but this never happened – the neurologist said there was conflicting nerve signals going to the muscle groups and that was that – he wasn’t interested in pursuing it any further)
• After about 2 years of seeking an answer, I gave up and switched to road cycling – have since won a Qld Time Trial championship – usually competitive in Masters Cycling esp. the Individual Time Trial and was cyclist of Masters Team winner (1999) at the Noosa Triathlon.
Current info.
• I experience a constant nagging & somewhat irritating discomfort around the right sacro-illiac area and the top of the hamstring / lower buttock area.
• Frequently catch right big toe on ground when walking esp when wearing slides or barefoot – often feel like I’m dragging the right leg around
• Walking very slowly (as I have to do when I take my mother grocery shopping) highlights some of the awkwardness of my gait.
• Seem to have developed an awkward gait - people sometimes ask me if I have an injury, to which I reply no, that’s just the way I walk now. Shoe salesman commented on it when I bought a pair of shoes from him recently and encouraged me to seek your advice.
• Tend to wear right shoe and inner sole under the right big toe (even my cycling shoe inner soles have a bare patch under the right big toe, left one no noticeable wear.
• My cycling shoes (ones I have had for the past 3 years) are “Specialised” Road Pro – have a 6 degree tilt toward the outside of the shoe – I bought them to try to alleviate pressure on my right knee caused by my foot rolling inwards during the pedal stroke and this has been successful.
• Consulted my physio, 18 months+ ago – much muscle tightness on right side esp ITB and hamstrings – had a set of stretches to work on which I did diligently for a few months but then got slack – he felt my problems were the result of a lack of flexibility in a number of areas.
Sounds like at might be something neurological originating from the back.
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?
Kent
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
Kent
Kent;
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.
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.
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
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:
History:
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.
Kent:
What exactly is his chief complaint (in 10 words or less)?
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
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
Regards
Mark
__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000
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:
I'll try to get the video posted ASAP.
Kent
Kent;
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!
Well, I too looked at the video, I'll stick with my original impression - OCD -
Obsessive-Compulsive Disorder.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Well, I too looked at the video, I'll stick with my original impression - OCD -
Obsessive-Compulsive Disorder.
Steve
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!
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
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?
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?
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?
Cheers,
Paul Dowie
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?
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?
Cheers,
Kent
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.
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
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???
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...(?)
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.
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.
Patient with 'awkward' gait
state, but could you tell me what AJE stands for?! 
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