The Value of Observing Gait
by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
The patient is a 58-year-old female, who has recently started a personal health and wellness program. In addition to eating more sensibly, she has initiated a daily walking program. After four weeks, she has progressed to 30 minutes of brisk walking everyday. She reports that she has been noticing lower back and right hip pain as she has increased the amount of her walking. She doesn’t recall any injury or specific strain.
Vitals. This female weighs 166 lbs and stands 5’4’’ in her stocking feet. This results in a BMI of 28, which is considered “overweight” (and she is getting close to obesity—a BMI of 30). Her blood pressure is 132/84, and her pulse is 76 bpm, with respirations at 16/minute. These findings are all slightly high, but considered within the normal ranges for her age. They are consistent with her being chronically “deconditioned,” as are many of our patients in this age range.
Posture and gait. Standing postural evaluation finds generally symmetrical development, with intact spinal curves and level iliac crests. She has moderate bilateral knee valgus and moderate calcaneal eversion, with a lower medial arch on the right. Gait screening identifies a distinct tendency to toe out on the right at heel strike, and she rolls off her right foot at toe off, rather than pushing off. This results from a combination of hyperpronation and a very ineffective toe off.
Chiropractic evaluation. Motion palpation identifies limitation in right sacroiliac motion, with moderate tenderness during Yeoman’s leg extension test. A compensatory lumbar fixation is identified at L4/5 on the left. No significant joint fixations are found in the feet and ankles. Manual testing finds no evidence of specific muscle weakness, and the deep tendon reflexes are bilaterally active.
Upright, weight-bearing X-rays of the lumbar spine demonstrate a loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels. There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is seen.
Bilateral pronation, which is more pronounced on the right, with poor toe off and “flare-out” of the right foot. This has resulted in right sacroiliac joint motion restriction and a compensatory lumbar fixation. Underlying degenerative processes likely contribute to her current symptoms.
Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as indicated.
Support. In keeping with the maxim, “When the foot hits the ground, everything changes,” her feet were scanned while bearing weight, and custom-made, stabilizing orthotics were ordered to support the arches, decrease calcaneal eversion and knee valgus, and to reduce the asymmetrical biomechanical forces being transmitted to the pelvis and spine. These inserts included support for the toe-off phase of gait, as well as materials to decrease heel-strike shock, in order to limit stress on her degenerated discs.
Rehabilitation. She was instructed to keep her brisk walking to 30 minutes for four weeks, before attempting to add any more time.
Response to Care
She tolerated the sacroiliac and spinal adjustments well, and commented that her “back feels much looser when I’m walking.” After a brief break-in period, she reported that the flexible, stabilizing orthotics produced a noticeable increase in her walking efficiency. She described feeling “more springy” as she walked, and she seemed to be more “energized.” Her low back and right hip symptoms resolved within the first two weeks of adjustments and wearing her orthotics. She was released from care after a total of ten visits over eight weeks, and had increased her walking to 45 minutes daily. She had also lost a total of 18 pounds since starting care.
This woman wanted to lose weight and improve her health, so she had started a walking program. Unfortunately, asymmetrical and inefficient biomechanics during the toe-off phase of her gait had caused back and hip symptoms. A brief evaluation of her gait, along with an assessment of her mid-stance foot alignment, quickly identified the underlying problems. Chiropractic care along with the support from stabilizing orthotics improved her alignment and foot function for more effective gait and reduced spinal stress.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation. He can be reached at [email protected].