Gait Symptoms

Case #1 (Nov 2002)

I have had two spinal surgeries since March, 2000.  Both to relieve (L4-L5) pain.  The pain is gone, but my walking is
impaired.  My gait is my problem. I lean into my walk and fall forward.  Any ideas about how to overcome this problem.  I've been taking therapy 3 times a week since February 2001. Is there any therapy I need to know about.

Leo Southern


Dear Leo and others interested,

I was just uploading this page to CGA when your mail came in:
/faq/arthritis.html

Prevalence of Self-Reported Arthritis or Chronic Joint Symptoms Among Adults - United States, 2001

The estimated U.S. prevalence of arthritis/CJS from this survey was a staggering 33% among adults! This represents approximately 69.9 million people. It is likely an overestimate, being based on self-reported data. Nevertheless, I find this data astounding and would be interested in any comment.
---

Leo's gait disorder is interesting in itself. With L4/5 spondylosis/radiculopathy we might expect a drop foot from weakness of the dorsiflexors of the foot (principally tibialis anterior). Thia would cause a reduction in clearance with scuffing during
swing phase, which doesn't seem to be his problem.

Leaning forward is usually an adaptation to apropulsive problems. By leaning forward, the ground reaction is placed more anterior and this aids the swing of the leg forwards. It is seen most obviously when climbing an incline, for example.

Thus I wonder if Leo's symptoms indicate a lack of push-off cuased by plantarflexor weakness. This would indicate S1 rather than L5 radiculopathy.

I get an increasing number of queries like this from people with gait disorders, and it is, of course, difficult to comment without a formal exam and gait analysis. However, I do there is something to be gained from speculating on the cause of symptoms in this way. Up till now, I think CGA has been perhaps over-dominated by engineering
considerations and it might be nice to swing the balance back a little toward the clinical side. It seems to me that we haven't yet established a firm connection between gait symptom and underlying disorder, although I recall that David Winter attempted one in the last chapter of his spiral-bound book (The biomechanics and motor control of human gait : normal, elderly and pathological). Here is my tentative list of gait symptoms:

I wonder what others think and whether you can add to this list?

Chris

Dr. Chris Kirtley MD PhD
Associate Professor
Dept. of Biomedical Engineering
Catholic University of America
620 Michigan Ave NE, Washington, DC 20064
Tel. 202-319-6247,  fax 202-319-4287
Email: kirtleymd@yahoo.com


Hello Leo and CGA Listmembers,

These symptoms bring to mind the possible loss of normal lumbar curvature (lordosis) during the surgeries, which would be a mechanical, rather than neurological cause for the symptoms.  Some have called such a condition the "Flat Back Syndrome" and have even gone so far as to operate again to restore the lumbar lordosis.

The "Flat Back Syndrome" requires a forward lean to bring the pelvis into it's accustomed, anteriorly "tilted" position. Otherwise, the pelvis remains "tilted" back, limiting hip extension and step length. Another symptom of the syndrome is excessive pressure under the ischial tuberosities during sitting, again because of the
posterior "tilt" of the pelvis.

Best regards for a good recovery Leo!

Larry Lamoreux (Engineer)
Lafayette, California


Thanks for the input.  I'm an old Athletic Trainer and Pedorthist.   I work in an Orthopaedic clinic and see a disproportionate amount of residual gait anomalies. This is very frustrating, because, they don't seem to be adequately addressed by  the PT and physician, in most cases.  Professionals seem to be so quick in saying, "well we've improved".  The patient wants to reach MMI, and that's not where they are always taken.

I don't have anything to contribute, but I'm sure eager to learn from y'all.

Stella Herrick


Hello, friends

I am a spine surgeon from Cali, Colombia and I have some things to ask for the case in mention. The surgery details and symptoms are not enough to explain the gait problems and recurrent pain. I  understand the biomechanic point of view of the biomechanics, but let us to know more about the case and limitations in Leo's functions to help him well.

Thanks,

Luis Felipe Villota E. MD


Dear Chris,

Good to see a focus on the clinical side of gait for us clinicians. Perhaps you may like to add to your list of gait abnormalities the following;

In other words, abnormalities of the frontal and transverse plane.

Any others?

Regards,
Martin Kidd


Dear colleagues,

I have read with interest the gait problem of Leo and the comments offered by distinguished workers in the field. I get the impression that Leo has obvious weakness of tibialis anterior but there appears to me there is subtle weakness in gastroc soleus as well. This makes Leo unstable in stance phase. I presume EMG has been done. There is no mention of the findings of weak muscles. I think therapy be continued if augmented walking is undesirable.

Dr. SRA Kirmani <zars@cyber.net.pk>
Consultant in PM&R practice


Chris and others following along,

Could it be that the underlying gait fault was either predisposing or perpetuating to the L4-5 back pain,and, w/ the pain resolved from the surgery, it is manifesting in another fashion.  In other words, he was hurting because he was limping, rather than limping because he was hurting.

I published a paper in 1999* describing the treatment of chronic lower back pain by altering gait style via the use of objectively fabricated custom foot orthoses.  The technique involves using in shoe pressure testing to create the orthotic device.   The study prospectively followed 32 patients previously being considered at or near medical endpoint for chronic lower back pain.  There was nearly a 50% decrease in objective outcome measurement (Quebec Back Pain Disability Scale) within the initial 3 months as compared to standard care measures.   At the conclusion (12-24 month F/U w/ 13.9 months average), the level of relief remained constant.  Since lower back pain is known to have a 70+% recurrence rate w/in 12 months, this was a very significant finding.

I would be happy to discuss this further if there is any interest.

*Dananberg, HJ, Guiliano, M, "Chronic Lower Back Pain And It Response to Custom Foot Orthoses",  Journal of the American Podiatric Medical Association, 89:3 March, 1999  pp109-117

Howard J. Dananberg, DPM
21 Eastman Avenue
Bedford, New Hampshire 03110
603-625-5772
fax 603-625-9889
howiedbpg@aol.com 


By applying a constraint to the person's gait (the orthotic), you may have shifted other components of their system, resulting in a new behavior pattern of gait and  a new postural organization. This may have been sufficient to change the alignment of the spine and the work of the trunk muscles in relationship to gravity. Research that has been conducted on Dynamic Systems Theory might be helpful to you. I have read your article witin the last month since I am reviewing pressure systems as part of my doctoral studies and for purchasing equipment for research purposes.

Terri Miller, PT, MS, CFP
SUNY Downstate
Brooklyn, NY 11203
(718) 270-7715 


Terri,

Thanks for the note.  The major change in gait style from the use of the orthotic device is sagittally oriented.  Hip extension at the conclusion of single support increases almost 50% when before and after are compared *.  I believe that w/ increased hip extension, the pre-swing phase is altered, w/ the ability to create greater acceleration prior to toeoff.  In other words,  when the trailing limb fails to extend, preswing acceleration decreases, and  therefore, at toeoff, iliopsoas overworks to create, rather than perpetuate swing motion.  It is the stress at the origin of the iliopsoas that eventually (after millions of repetitive cycles) causes LBP symptoms.

* Dananberg, HJ, "Gait Style and Its Relevance in the Management of Chronic Lower Back Pain", In Proceedings, 4th Interdisciplinary World Congress of Low Back & Pelvic Pain", Ed, Vleeming, A, Mooney. V, Gracovetsky, S, Lee, D, et al, November 8-10, 2001, pp 225-230

Howard Dananberg, DPM
21 Eastman Avenue
Bedford, New Hampshire 03110
603-625-5772
fax 603-625-9889
howiedbpg@aol.com 


I agree with what you said about the iliospoas being a possible contributor. What position is the pelvis normally in when sitting and standing and how does that relate to body segments above and below. The orthotics can make a change in the system to get someone out of back pain by shifting mechanics and muscle activity. What is spinal mobility like? Something else you might look into is Feldenkrais which can help with increasing awareness of postures and movement patterns that contribute to the back pain and for guided self-discovery of new options.

Terri

Terri Miller, PT, MS, CFP
SUNY Downstate
Brooklyn, New York, 11203
(718) 270-7715 


Leo and CGA list,
        I wish to recap some of the ideas offered by other cga respondants. First of all, in saying you are "taking" therapy 3 times a week for quite some time, it sounds like a "medication" or a situation in which you have been a passive recipient. Perhaps you are asking for a more active intervention focus.
        The advice from Terri Miller refers to Dynamic Systems Theory. As applied to human motor performance, the Dynamic Systems framework foranalysing movement dyscontrol could describe your leaning/fallingpattern during gait as a difficulty organizing your body (coordinating awhole chain of individual joints and muscles) so that your center of mass (COM) remains easily over your base of support. If you can organizeyourself so that your COM is closer over the center of the base ofsupport, less effort will be required to maintain your upright posture.Your difficulty could be any one or a combination of the possibilitiesmentioned in other responses through the cga listserve, or something  else. We don't know your history and we can't see your movement patterns. A hypothesis for your case: while walking using imbalanced foot dynamics for thousands of steps over many years since early childhood, you created secondary abnormal spine movements that led to the back pain originating at L4 and L5. (I have not read Dr. Dananberg's  article yet, but I gather from his remarks that his research provides evidence for this pattern.)
        Your spinal surgery then "blocked" the abnormal spine movement (perhaps it also flattened the normal curve in the low back). Since surgery, your body has not been able to find another internal way (through joint motion) to compensate for the original problem (abnormal foot movements), so now you compensate by leaning forward. In this case, the
way to approach the problem is to do what you can to compensate for the primary (foot) problem, as well as work on the secondary aspects (musculoskeletal limitations). Working at correctiion of the foot dynamics might be approached by using an orthotic to bring the "floor" up to meet your foot at the proper time while walking. In addition, work on developing active flexibility and strength in the muscles that control your pelvis and your spine (the secondary problem). Perhaps you have a shortened hip flexor, the psoas, or overall imbalance between the muscles that control the position of your pelvis, or stiffness throughyour upper spine. A therapist should help you identify the specific areas, but the work will be up to you.
        I am a pediatric physical therapist and I stretching my limits to be talking about adult back problems. I work with a whole variety of children, including many with significant musculoskeletal issues such as cerebral palsy. I am especially interested in the development of gait and movement patterns during childhood and the way that early movement patterns might affect long-term musculoskeletal outcomes.
        I hope my remarks have been helpful.

Elaine Clark, MPT
2415 E McGraw St.
Seattle WA 98112
(206) 726-9379

Case #2 (Dec 2002)

Dear all,

                      Following on from last month's case, I have just been approached by this
                      man, who gives quite a detailed history. He would grateful for your
                      comments/analysis.

                      Chris
                      ---
                      I have never done this before so please bear with me.

                      I am a 56 yr old male, 6'4", 275 lbs.
                      In 1958 at age 12, I began to notice a slowing of my running speed.  I
                     sprained my ankles constantly, and perhaps damaged them beyond repair.
                      It got to the point that I could hardly run.  At this time I experienced
                      a weakening in my legs below the calfs accompanied by loss of muscle
                      mass - atrophy.  I have a loss of muscle and atrophy in this area to this
                      day. I may even have some torn ligaments or tendons from the falls I
                      took in my formative years.

                      I have no idea if the above resulted from a disease, hereditary defect,
                      injury, nerve disorder, spinal problem, bad polio vaccine or
                      something else.  I don't know if there is a connection but, I recall
                      that during this time I experienced a significant amount of "itching"
                      in my lower leg below the calves, yet above and around the ankle area.

                      Today I have a strange gait, weak ankles and am prone to falling with a
                      twisted ankle, generally because my right foot rotates back
                      and outwardly with any irregularity of terrain.  As I get even older
                      this scares me.  You know the drill, fall, broken hip, nursing home
                      etc.

                      Can you please give me some insight as to where I might seek assistance
                      in determining if there is anything I might do to recover
                      any muscle mass, stabilize my leg/ankle, and/or improve my gait so I can
                      move better with a firmer footing?   Podiatrist, neurologist, orthopedic specialist etc

                      I live in the Tampa-St.Petersburg-Clearwater area of Florida USA

                      I had heard a Dr. once mention Charcot Marie Tooth, but I am not sure if this fits.

                      I'm not aware of any hereditary concerns, and the progressing
                      atrophy/weakening problems seemed to end by age 15.  That is, symptoms first appeared at age 12, and the
                      damage was done by age 14/15.  I don't have any progression into my hands or arms.

                      However, I do have very high arches, a "hammer toe" foot appearance, and
                     cannot raise up on my toes very well (barely on the left foot and not at all on the right).
                      When I walk, it is stilted, I have a hard time keeping up a normal pace.  I believe my
                      right foot pronates out and back with each step.

                      I always wondered if there could have been some problem in the lower
                      back that "pinched" a nerve and inhibited the normal impulses.  As the pinched area stabilized
                      perhaps it stopped the progression of muscle atrophy. I wonder about surgery to stabilize the
                      foot/ankle area.

                      I am concerned if I should see someone at a Spine Center or an
                      Orthopedic Specialist of some nature.   Perhaps a podiatrist.  I am looking for direction, if there is any.


Dear all,

                      Thanks for the comments so far. We've also had a kind offer from a lab in this man's locality to
                      review him. If this goes ahead we'll report the findings.

                      In the meantime, I thought it might be helpful to summarize the main features:

                      - age 56
                      - onset at age 12
                      - bilateral involvment (R > L)
                      - slowly progressive
                      - "itching" in lower legs
                      - weakness standing on tiptoes
                      - atrophy in the lower legs
                      - cavus feet
                      - right foot rotates externally
                      - no upper-limb symptoms

                      Le's apply the pathological sieve...

                      - congenital: Charcot-Marie-Tooth has been raised. This is certainly a strong possibility in my
                      opinion. True, there are no upper-limb symptoms, but don't think this rules CMT out. The rest of
                      the picture and natural history is quite consistent.
                      - infective: Paul raised the possibility of poliomyelitis, which is worth considering. It would be
                      unusual as late as 1958 (the last epidemic in the US was 1955, and I assume he was not from
                      overseas). Also, there seem to be sensory symptoms (the "itching").
                      - inflammatory: too early for MS
                      - vascular: the early onset also rules this out
                      - neoplastic: too long a history
                      - traumatic: sciatic is always a possibility (remember the maxim "rare manifestations of common
                      diseases are commoner than common manifestations of rare diseases"), and at 58 this could
                      complicate the picture, but Ockham's razor requires us to search for a single diagnosis
                      - degenerative: once again, unlikely with the early onset, but note that post-polio symptoms often
                      present as a "new" condition (e.g. Arthur C Clarke, who is now severely disabled from post-polio
                      yet had only a very mild initial involvement).

                      In summary, then, I would plump for CMT. It would be interesting to enquire more about any other
                      family symptoms (though sporadic CMT is possible, it's rare). Nerve conduction studies and EMG
                      would be very helpful, and I believe there's a DNA test these days for some forms of CMT.

                      As far as treatment, I agree that orthotics offer most potential. The external rotation of the
                      right foot does raise the possibility of hip involvment, which would not be in keeping with CMT
                      and unlikely to be helped by orthoses. It would be nice to see a video, of course.

                      I look forward to your further comments.

                     Dr. Chris Kirtley MD PhD
                      Associate Professor
                      Dept. of Biomedical Engineering
                      Catholic University of America
                      620 Michigan Ave NE, Washington, DC 20064
                      Tel. 202-319-6247,  fax 202-319-4287


                    The age of onset (at 12 y/o in a 56 y/o) makes the year of occurrence about
                      1958.  The date of onset, plus the lack of subsequent progression, and the
                      primary involvement being muscle weakness/atrophy suggest that the initial
                      pathology may have been polio.  I would suggest visiting a neurologist for
                      a definitive testing and diagnosis and then a Physical Medicine and
                      Rehabilitation physician for recommendations regarding orthotics, a fall
                      prevention program, and treatment, if appropriate, for post-polio
                      syndrome.  I would suspect the PM&R doc would refer the individual to a
                      physical therapist and also to an orthotist.

Paul Hansen
Fircrest Physical Therapy
Fircrest, WA  98466


Hi Chris,

                      We are also a gait lab in the vicinity of your patient's locality (Seminole, Florida). The name of our
                      clinic is The Florida Biomechanics Group. We have two doctors: Robert Levine, DPM and myself,
                      Robert Rice, DC, MS. We perform gait analysis as well as custom foot orthotics, and rehabilitation to
                      mention a few. Our clinic motto is "If you don't walk right, you don't work right!) Dr. Levine and I would
                      be honored to help out in any way possible.

                      Thank you,

Robert P. Rice, D.C., M.S.
D.C. Florida Biomechanics Group
727-393-2383


                    As a physical therapist who has worked extensively with both Charcot Marie
                      Toothe and MS I agree that CMT is the more likely. However, your comment that
                      "rare manifestations of common diseases are commoner than common
                      manifestations of rare diseases" behooves me to point out that, that MS can,
                      however rarely, effect persons of so young an age. The treatment options for
                      the two diseases are quite different

Herbert I. Karpatkin, PT, NCS
Touro College
New York


Dear list,

                      I agree with Chris that there are many potential alternative diagnoses that
                      could explain this gentleman's symptoms.  However, ruling out polio based
                      solely upon that the onset was not during an epidemic year may not be
                      appropriate.  Agreeably, there multiple polio epidemics during the early
                      1900's, even after the introduction of a vaccine in 1955/1956.  While its
                      incidence was reduced significantly, it was still relatively common during
                      the late 1950's, until actually 1962.

                      Total cases of poliomyelitis in the US by year:
                               1955 -- 28,985
                               1956 -- 15,140
                               1957 -- 5,485
                               1958 -- 5,787
                               1959 -- 8,425
                               1960 -- 3,190
                               1961 -- 1,312
                               1962 -- 910
                      from: www.cdc.gov/mmwr/PDF/wk/mm4253.pdf

                      While there were fewer cases of polio in 1958 than in 1955, there were
                      still thousands that were recognized in 1958.  Thus, the possibility of
                      polio should be considered until ruled out by examination.

Paul Hansen
Fircrest Physical Therapy
Fircrest, WA  98466


Here are a few more comments from the patient...

I read the discussions on the web and they are very interesting. I might also offer these additional insights for discussion.

Right after or during the mass polio vaccinations that went on in the late 1950s there were
scares of batches of "bad vaccine" being distributed and administered that were actually
causing polio. As I recall, as kids, we had to have a series of shots (maybe 3) in the series
at that time. Could I have gotten a "bad vaccine" shot in the series?  Could this be a
potential?

I believe the biggest clue is the 'itching while standing' that I experienced in the area below
the calves and around the ankles.  This occurred only when I would stand in a location with
very little movement for a period of time.  In particular I recall; 1) washing and/or drying
dishes in the kitchen with my mother, where I would stand adjacent to the sink area for a
period of time.  The itching would begin in perhaps 3/5 minutes.  I would "hop" around rubbing
my lower leg calf areas together and my mother would always ask "What's wrong with you?  Stop
jumping around!" (I recall making a run for the sofa to sit down and scratch my legs for 30
seconds or so, then I was ready to play)

2) In church, years ago I was an altar boy and would stand for periods of time during the mass.
Again the itching would start.  When I was able to move around it would subside, and again, go
away when I could sit down.

The itching was always localized to the same area, lower calf, ankle area and it was intense.
However, It always went away when I sat down.  It never occurred when I
was walking/running/playing or at night before or during sleep as I recall.
I'm sure I never was awakened because of it.  Rather to the best of my memory it only
occurred when I was required to stand up in a reasonably stationary position for any length of time.
It always became less intense when I could walk/move and (as I said) went away when I could sit.

For the record my father did have the very high arches on his feet, accompanied by high insteps.  He could never where loafers.  In addition, I recall he wore arch supports with a metatarsal support as well.  I remember them to be made of stainless steel and he would complain that his feet hurt him.

Could there have been some complication from the growth spurt during puberty?  Perhaps some structural spine problems causing a pinching of nerves?  Perhaps circulation limitations caused by being a tall skinny fast growing kid? Could CMT come into my life for limited time, damage me and just leave?


Hello All,
    This is a really interesting patient and situation.  My first thought after
reading Chris's first email was "polio"--definitely still a possibility in the
late '50s [I was in jr. high and high school; our much beloved band
director died of it, within 36 hours of becoming ill]. I'm not sure if the
itching was a common symptom--I got to my orthopedic residency just
too late to ever see an acute case; but couldn't vascular stasis produce
those symptoms? The preservation of sensation is what keeps me
thinking polio, instead of CMT.
    However, the history of this man's father's feet makes CMT a good bet
too. How many CMT pts never show upper limb changes??

Anyway, I agree about the treatment--bracing and therapy, and
'balancing' surgery for the cavus feet if necessary [to improve/increase
weight-bearing surfaces and shoe fit].

Thanks for the interesting case and discussion,

Mary Willliams Clark MD
Pediatric Orthopedics, Sparrow
Lansing Mich..