BACKGROUND AND HISTORY
Female, 55 at time of this assessment in early 2018. Referred for gait analysis.
Client attended with pain in both feet legs, and had reduced mobility stating that she felt that her legs were heavy and tired after only a few minutes of walking. The feet feel tender all of the time but once she walks for 20 minutes, her legs feel heavy as though she has worn a new pair of shoes and this will be worse than the feet.
The pain had begun with some plantar fasciitis and had moved to the knees also. She had been experiencing these pains for around 3 years and had seen several specialists and was waiting for an appointment for spinal stimulation therapy. Any significant spinal pathology had been ruled out, she had been assessed for chronic pain and there is no evidence of an inflammatory arthropathy. Blood tests, CT angio an MRI of the lower legs were all normal.
Previous to this the patient had been relatively fit and enjoyed walking and gardening, which she was now unable to do. She was swimming regularly as this was the only exercise that didn’t routinely make the pain worse. This was initially plantar fasciitis, She has been referred for gait analysis.
- CVS. Both pedal pulses palpable bilaterally.
- CNS. There were some posterior tension signs on straight leg raise but this was otherwise normal.
- LS. Given her symptoms, there was minimal discomfort on palpation of the plantar fascia or plantar heel.
Biomechanical evaluation revealed (bilateral unless stated):
- Adequate rearfoot motion.
- The left forefoot appears parallel with the right slightly everted to the rearfoot.
- On weight-bearing, both heels are relatively perpendicular to the supporting surface and she maintains a medial longitudinal arch.
- Foot Posture index L/0, R/-1 (Reference values - Highly supinated: -5 to -12, Supinated: -1 to - 4, Normal: 0 to + 5, Pronated: +6 to +9, Highly pronated: 10+).
Observational gait analysis: On walking, she appeared to have a short step length with early heel lift and increased ankle plantarflexion. If anything, there appeared to be a low gear toe off.
3D GAIT ANALYSIS MAIN OBSERVATIONS (WALK)
• Power Generation: There is slightly high hip extension and thus reduced pelvic tilt with left ankle dorsiflexion high.
• Control: There is some asymmetry although hip adduction is excessive with knee abduction reduced bilaterally.
• Ankle: Consistent with her foot structure, there is reduced eversion but as there is a higher level of inversion at heel strike, the eversion range is high with a high velocity.
• Gait Parameters: This confirms a short step length.
• Strength: This was revealing in that there is a deficit in all muscle groups and it is interesting that she has reduced hip extension strength yet relatively high hip extension at toe off. She is particularly weak about both ankles.
• Flexibility: This was generally good except for calf inflexibility.
Although there is some asymmetry on the gait analysis, she has symmetrical symptoms and thus, in my opinion, the key findings are a tendency towards an ankle dominant gait as there is an early heel lift with increased ankle plantarflexion in latter stance with a short step length. I suspect some of the increased hip extension is reflective of lower back motion and there is poor control in terms of hip adduction.
Furthermore, at the foot, although the degree of eversion is reduced, the overall range of motion from heel strike to maximum eversion is increased with a high velocity requiring greater control. All of these factors will be exacerbated by the general muscle weakness
1. Footwear: Based on the results, a neutral shoe should be sufficient. I have advised her to get a good running shoe for support and to have a laced version. One option going forward would be to consider the Hoka shoe given the rocker sole adaptation but I would prefer her to concentrate on rehab in the first instance.
2. Orthoses: At this moment in time, I do not feel orthoses are required but this can be revisited according to symptoms.
3. Flexibility: The objective clinical evaluation indicates that the key areas to target are: Gastro-soleus.
4. Strength and Conditioning: The objective clinical evaluation indicates that there is a general deficit which needs attention but the key areas to target are: Hip extension, abduction and external rotation, ankle inversion and eversion. Detailed below are the muscle groups relating to the specific areas of altered function with a view to optimising movement patterns.
- Pelvic obliquity (R): Hip abductor/extensor/external rotator
- Pelvic rotation (L): Hip abductor/extensor, Transverse abdominus, multifidus
- Hip adduction: Hip abductor/extensor, ankle inversion / eversion
- Knee rotation (R): Hip abductor/flexor/internal/external rotator, hamstring
- Pelvic tilt: Hip flexor
- Pelvis and hip rotation (R): Hip flexor
- Knee abduction: Hip internal / external rotator
- Rearfoot eversion: Hip abductor, ankle inversion / eversion
5. Neuromotor Control: Optimising control will be an important feature of the rehab.
6. Mobilisation: There is no indication for mobilisation.
7. Gait Parameters: She has a short step length and does appear to have increased ankle plantar flexion towards toe off. Thus trying to improve the step length with power generation via the hip should help to reduce load through the foot.
She has an ankle dominant gait with likely compensation in the lower spine providing a false degree of hip extension. In addition, of note, is the excessive hip adduction. All of this is exacerbated by general weakness. At the ankle, there is a high overall range of motion and velocity and thus improving strength and control around the ankle would be of benefit. I recommended she see Ken Hoye for appropriate rehab guidance and I will review in 3 months to assess progress and further options.
The MSK revealed strength deficit across most areas with good mobility with the exception of calf complex. Although she was able to complete 30 calf raises and the bridge exercises, her balance scores were low, including control in squat, and she failed most of the bridge tests. Her 3D Gait showed asymmetrical pelvic motion and high hip adduction, so we began the exercises to address this and look at improving her balance. This improved her confidence and allow us to build up the difficulty of the exercises quicker.
The patient was keen to improve and felt that we were the first people she had seen that could offer a solution, and as she could see what needed to be worked on was fully committed to the program. Initial exercises were limited by her lack of balance so we began with some inversion and eversion exercises with a theraband. We added split squad which she initially did next to the wall to use as support if needed. Some of these exercises were performed in the swimming pool as the patient continued to swim and added these exercises here as she felt more confident doing them in the water.
A couple of weeks later and there was already an improvement so we progressed the exercises adding dead bug, and step ups with balance at the top position. This worked strength, balance and coordination and provided a challenge to her which she was keen to embrace. We also did Glute kicks with 4 point kneeling to engage the glutes and work on the hip position whilst activating the core.
At 5 weeks after initial test we were able to progress to forward lunge as balance had improved considerably. We still kept the movement relatively short but advised on increasing the step length of this exercise as a goal. We also added hip abduction with theraband to improve glute and hip strength with control and balance also challenged. Crab walks were introduced for similar reasons and to make the program more interesting. Client was also able to add some weights to her step up increasing the level of difficulty whilst maintaining the challenge to both strength and control. She mentioned she had some pain recently after spending too much time gardening, but that she would not have been able to do any gardening previous to her assessment. We discussed moderating the exercises on days when she had any discomfort.
After one further session reviewing her exercises and discussing progression we decided to allow her to continue her exercises on her own and only attend if needed. She had said she had met some friends for dinner which she had been avoiding as she had found it difficult to get up from a chair and felt embarrassed. She was now able to do this and move much more easily to and from the table. She now only had any discomfort on days she had been overdoing her activity and was more confident doing many tasks she had not been able to do for some time. She had even added a couple of minutes of running to her gym routine.