Possibly the most important learning outcome that I will teach during my workshop on gait is the importance of fusing history taking, kinematic observation, muscle balance assessment and knowledge of motion science together so that a full picture of the patient can be seen. These factors are all necessary in determining the true root cause of pain and dysfunction. An over reliance on one of these factors may result in poor diagnosis and treatment. The following brief case history highlights this.

A male patient presented to me with excessive limping and knee pain post hip replacement. I had worked with this man before his hip surgery and his limp, due to pain from his arthritic hip, was characterised as slight external hip rotation and excessive side flexion of the upper body towards the arthritic hip.

History taking was lengthy as was the muscle balance assessment but the main findings were

* Gluteals were strong in extension and abduction but slightly weak in resisted external rotation.

* Quads were strong and no pain inhibition on single leg bend

* Calf was strong in heel lift

* Patient was getting physiotherapy treatment

* No groin, hip pain

* Patient did not have pain while doing rehabilitation exercises

* Hip was not painful during ROM testing

* Patient was still worried about dislocating his hip with forward flexing tasks and his wife would help him put his socks on

* Patient felt comfortable about his hip but was concerned about knee pain and he was mystified about his limp.

Gait Assessment

By observing gait I noticed

* Side flex forward affected hip was gone.

* Initial contact and mid stance phase kinematics were normal

* During the propulsion phase of gait the knee flexed excessively and the heel failed to lift, i.e. the ankle continued to dorsiflex. This caused a significant sagging on the affected side.

What was the cause of the limp? What was causing the pain in the knee?

What are the key factors from case history, muscle balance and kinematic observations?

Case History –

* Patient can’t reach the foot on affected side

Muscle Balance –

* No pain inhibition of hip, knee or calf

* Muscles all strong enough to support function

Kinematic Observation –

* Poor function seen in propulsion phase only

* 0 degree heel lift

* Excessive Knee flexion in propulsive leg

I concluded that the failure of the heel lift was the root cause of the limp and the reason for the lack of heel lift was due to not being able to lace up the shoe on the affected side. This inability to lace the shoe caused the shoe to slip off the foot while plantarflexing the ankle during the propulsive phase of gait. But by not lifting the heel the shoe stayed on the foot.

Easy to test – I laced up the shoe and prompted heel lift – near normal gait resumed.

The Science!!!  -  A little thing called the plantar flexor – knee extensor couple. This is a mechanism where powerful plantar flexion of the foot directs the ground reaction force vector into a position that the knee is being extended, without planter flexion power the knee extension failed.

I think this case highlights how history taking, physical assessment, gait observation and knowledge of motion science are needed to fully understand our patients’ pain and dysfunction experience.

...Oh his wife laces up his shoes too now.