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:
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
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
I don't have anything to contribute, but I'm sure eager to learn from y'all.
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,
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;
Any others?
Regards,
Martin Kidd
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
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
Terri Miller, PT, MS, CFP
SUNY Downstate
Brooklyn, NY 11203
(718) 270-7715
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
Terri
Terri Miller, PT, MS, CFP
SUNY Downstate
Brooklyn, New York, 11203
(718) 270-7715
Elaine Clark, MPT
2415 E McGraw St.
Seattle WA 98112
(206) 726-9379
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.
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
Paul Hansen
Fircrest Physical Therapy
Fircrest, WA 98466
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
Herbert I. Karpatkin, PT, NCS
Touro College
New York
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
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?
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..