Apparent Leglength Discrepancy Caused By Muscle Imbalance

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Without any actual difference in leg length, subjects have an appearance of a longer leg on the high side when the pelvis is tilted laterally. In the right photograph below, this appearance has been created by displacing the pelvis laterally. (The feet were anchored to the floor.)

If tightness develops in the tensor fasciae latae and iliotibial band on one side, the pelvis will be tilted downward on that side. With gluteus medius weakness on one side, the pelvis will ride higher on the side of the weakness.

The habit of standing with the weight mainly on one leg and the pelvis swayed sideways weakens the abductors, especially the gluteus medius on that side. If tightness of the tensor fasciae latae on one side and weakness of the gluteus medius on the other is mild, treatment may be as simple as breaking the habit and standing evenly on both feet. If the imbalance is more marked, treatment may involve stretching of the tight tensor fasciae latae and iliotib-ial band and use of a heel lift on the low side. The lift will help stretch the tight tensor and relieve strain on the opposite gluteus medius. (For a detailed discussion, see p. 398.)

Apparent Limb Length Discrepancy

Legs are equal in length. Pelvis is level.

Both hip joints are neutral between adduction and abduction. Length of abductors is equal.

Muscular Leg Length

As the pelvis sways sideways, the pelvis is higher on the right.

The right hip joint is adducted.

The left hip joint is abducted.

The right hip abductors are elongated.

The left hip abductors and fascia lata are in a shortened position.

FOOT PROBLEMS

The foot has two longitudinal arches that extend lengthwise from the heel to the ball of the foot. The inner or medial longitudinal arch is made up of the calcaneus, astragalus, scaphoid, three cuneiform, and three medial metatarsal bones. The outer or lateral longitudinal arch is made up of the calcaneus, cuboid and two lateral metatarsal bones. The outer arch is lower than the inner arch, and it tends to be obliterated in weight bearing. Any references to *'the longitudinal arch" will therefore mean the inner arch.

There are two transverse metatarsal arches, one across the midsection and one across the ball of the foot. The posterior metatarsal arch is at the proximal end (or base) of the metatarsal bones. It is a structural arch with wedge-shaped bones at the apex of the arch. The anterior metatarsal arch is at the distal ends (or heads) of the metatarsals.

Painful foot conditions may be roughly divided into three groups:

1. Those dealing with longitudinal arch strain.

2. Those dealing with metatarsal arch strain.

3. Those dealing with faulty positions of the toes.

The three types of painful conditions may exist in the same foot, but more often, one type predominates over the others.

Examination of faulty and painful feet should include the following steps:

Examine the overall postural alignment for evidence of superimposed strain on the feet, such as occurs in cases of postural faults in which the body weight is borne too far forward over the balls of the feet (see p. 69).

Check the alignment of the feet in standing, both with and without shoes.

Observe the manner of walking, both with and without shoes.

Test for muscle weakness or tightness of the toe and foot muscles.

Check regarding unfavorable occupational influences.

Examine the shoes for overall fit (see p. 444), and check for places of wear on the sole and heel. Faulty weight distribution in standing or walking is often revealed by excessive wear on certain parts of the shoe.

Treatment may be considered as being of two types, corrective and palliative. Ideally, treatment should be corrective, but considering that painful foot conditions occur in many older people who have bony, ligamentous, and muscular structures that cannot adjust to corrective measures, it is necessary to use measures designed to obtain relief with the minimum of correction.

FAULTY AND PAINFUL FOOT CONDITIONS AND TREATMENT INDICATIONS

There is a familiar saying, "If your feet hurt, you hurt all over." For those whose occupation requires constant standing, or those engaged in activities that place great stress on the feet, the statement is especially applicable.

In older people, feet may become painful because of the loss of normal padding on the soles of the feel. Insoles that cushion the foot markedly improve comfort and function. The insole must be thin enough to fit in the shoe without crowding the foot, but thick enough to offer a firm, resilient cushion.

To the extent that the foot pain or discomfort is relieved, the insole may indirectly help alleviate the discomfort elsewhere that has resulted from a painful foot condition.

PRONATION WITHOUT FLATNESS OF THE LONGITUDINAL ARCH

This type of fault is most often found among women who wear high heels. In weight bearing, some symptoms of foot strain may occur in the longitudinal arch, but more often, the pronation causes strain medially at the knee. In the foot itself, the anterior arch is subjected to more strain than the longitudinal arch.

Occasionally, the longitudinal arch is higher than average. This situation may require use of an arch support that is higher than usual so that the support may conform to the foot and provide a uniform base of support.

Treatment of pronation consists of using an inner heel wedge or an orthosis that provides the same type of correction. Generally, patients should be discouraged from wearing a high heel if they have symptoms of foot or knee pain. Recommending shoes with little or no heel may be inadvisable, however, because the foot tends to pronate more in a flat-heeled shoe. With a medium heel, the longitudinal arch is increased, and a heel wedge or arch support will help to correct pronation.

Regarding shoe correction, on a heel of medium height, a '/(6-inch inner wedge is usually used, whereas a '/s-inch wedge is the usual adjustment on a low heel. A high heel cannot be altered by use of an inner wedge without interfering with the subject's stability.

PRONATION WITH FLATNESS OF THE LONGITUDINAL ARCH

This position of the foot is comparable to a position of dorsitlexion and eversión. In weight bearing, the position of pronation with flatness of the longitudinal arch is usually accompanied by an out-toeing of the forefoot. Excessive tension is exerted on the muscles and ligaments on the inner side of the foot that support the longitudinal arch. Undue compression is exerted on the outer side of the foot, in the region of the talocalca-neonavicular joint.

The tibialis posterior and abductor hallucis are usually weak. Toe extensor muscles and the flexor brevis digitorum also may be weak. The peroneal muscles tend to be tight if pronation is marked.

Supportive treatment consists of using an inner-heel wedge and a longitudinal arch support. When the heel has a wide base, a wedge of Ms-inch thickness is most often used. When the fault is severe, the patient should be discouraged from wearing a shoe without a heel. This type of fault is more prevalent among men and children than among women.

SUPINATED FOOT

A supinated foot is a very uncommon postural fault (see p. 80). It is essentially the reverse of a pronated foot— the arch is high, and the weight is bom on the outer side of the foot. Likewise, shoe corrections are essentially the opposite of those applied to a pronated foot. An outer wedge on the heel, a reverse modified Thomas heel, and an outer sole wedge usually are indicated.

If the knock-knee is associated with supination of the foot, shoe corrections as described above may increase the deformity of the knee. Give careful consideration to any associated faults.

HAMMER TOES

Massage and stretching may aid in correcting the faulty alignment of the toes in the early stage, and benefit may be obtained from use of a metatarsal bar. An inside metatarsal bar may be more effective, but an outside metatarsal bar may be more comfortable. (See figure, p. 445.)

The position of hammer toes (as illustrated) is one in which the toes are extended at the metatarsophalangeal and distal interphalangeal joints and are flexed at the proximal interphalangeal joints. Usually, calluses are found under the ball of the foot and corns on the toes as a result of pressure from the shoe. Shoes that are too short or too narrow can contribute to the problem.

METATARSAL ARCH STRAIN

This type of strain is usually the result of wearing high heels or of walking on hard surfaces in soft-soled shoes. It also may result from an unusual amount of running, jumping, or hopping. An interesting and unusual example of the latter was observed in a child of approximately 10 years of age who had won a hopscotch tournament. The foot on which she did most of her hopping had developed metatarsal strain and a callus on the ball of the foot.

In cases of metatarsal arch strain, the lumbricales. adductor hallucis (transverse and oblique), and flexor digiti minimi are most noticeably weak. If asked to flex the toes and cup the front part of the foot, the patient can only flex the end joints of the toes; little or no flexion of the metatarsophalangeal joints occurs.

Stretching of the toe extensors is indicated if tightness exists. Supportive treatment consists of use of a metatarsal pad or a metatarsal bar. If calluses are under the heads of the second, third, and fourth metatarsals, a pad is usually indicated; if calluses are under the heads of all the metatarsals, a bar is indicated.

HALLUX VALGUS

A hallux valgus is a position of faulty alignment of the big toe in which the end of the toe deviates toward the midline of the foot (see figure, p. 83), sometimes to the point of overlapping the other toes. The abductor hallu-cis muscle is stretched and weakened, and the adductor hallucis muscle is tight.

Such cases may require surgery if the fault cannot be corrected or the pain alleviated by conservative means. In the early stages, however, it may be possible to achieve considerable correction.

The patient should wear shoes with a straight inner border and avoid shoes with cut-out toe space. A "toe-separator," which is a small piece of rubber, is inserted between the big toe and the second toe aids in holding the big toe in more normal alignment. As a pure palliative procedure for the relief of pain caused by pressure, a bunion-guard is often useful.

Because excessive pronation often is the cause of the hallux valgus, prevention or correction require that the arch be supported. "Excessive" means marked relaxation of the supporting arch structures that require firm support; rigid orthoses are needed in such instances.

IN-TOEING POSITION OF THE FOOT

An in-toeing position of the feet, like the out-toeing position, may be related to faults at various levels. The term pigeon-toes may be considered to be synonymous with in-toeing.

If the legs are internally rotated at hip level, the patellae face inward, the feet point inward, and usually, pronation of the feet occurs. With in-toeing related to medial torsion of the tibia, the patellae face forward, and the feet point inward. If the problem is within the foot itself, the hips and knees may be in good alignment, but anterior foot varus (i.e., adduction of the forefoot) may be found. (See photo, below.)

Generally, children do not exhibit muscle tightness. It is not uncommon, however, to find that the tensor fasciae latae, which is an internal rotator, is tight in children who exhibit medial rotation from hip level. Stretching of the tensor may be indicated, but this should be done carefully.

Children who develop this medial rotation from hip level often sit in a reverse tailor or "W" position. (See photograph, p. 448) Encouraging the child to sit in a cross-legged position tends to offset the effects of the other position.

The shoe correction used in cases of in-toeing associated with internal rotation of the extremity is a small semicircular patch, placed on the outer side of the sole at about the base of the fifth metatarsal (see Figure C, p. 445). To mark the area for the patch, the shoe is held upside down and bent sharply at the sole, in the same manner that it bends in walking. The patch extends about equally forward and backward from the apex of the bend.

The patch is of a given thickness (either '/s or 3/i6 inch, depending on the size of the shoe) along the outer border. It tapers off to zero toward the front, center, and back of the sole.

In-toeing associated with internal rotation of the extremity tends to be more marked in walking than in standing, and the shoe correction helps to change the walking rather than the standing pattern. The effect of changing the walking pattern, in turn, helps to correct the standing position.

The patch, by its convex shape, pivots the foot outward as the sole of the shoe is brought in contact with the floor during the usual transfer of weight forward. Before marking the shoe for alteration, a leather patch may be taped to the sole of the shoe and tested for position by observing the child's walk.

An in-toeing position caused by malalignment of the forefoot in relation to the rest of the foot is similar to a mild clubfoot, without equinus or supination of the heel. As a matter of fact, there may be pronation of the heel along with the adduction. (See below.)

Inflare shoes may be comfortable, but they will not be corrective. The child should be fitted with shoes that have been made on a straight last. A stiff inner counter, extending from the base of the first metatarsal to the end of the great toe, should be added to the shoe. The outer counter should be stiff from the heel to the cuboid.

When shoe alterations fail to bring about a correction of the in-toeing, a "twister" may be used. (See following page.)

Anterior foot varus and in-toeing right foot.

External rotation of hips and out-toeing of feet.

OUT-TOEING POSITION OF THE FEET

Out-toeing may be the result of (a) external rotation of the entire extremity from hip level (b) tibial torsion, in which the shaft of the tibia has developed lateral rotation (c) or a fault of the foot itself in which the forefoot abducts in relation to the posterior part of the foot.

For young children in whom the problem is from hip level, a twister may be used. Usually, results are obtained within a relatively short period of time (i.e., several months) (see below).

The external rotation of the extremity (see figure on the facing page) does not automatically cause difficulty in standing. Walking in an out-toeing position, however, tends to put strain on the longitudinal arch as the weight is transferred from the heel to the toes.

If tibial torsion is an established fault in an adult, no effort should be made to have the individual walk with the feet straight ahead. Such "correction" of the foot position would result in a faulty alignment of the knees and hips.

Abduction of the forefoot is the result of a breakdown of the longitudinal arch. In children, measures that correct the arch position will help to correct the out-toeing. Wearing corrective shoes may be advisable, because they typically have an inflare last. In adults with an established fault, however, corrective shoes do not change the alignment of the foot but, rather, cause undue pressure on the foot. Usually, it is necessary to have the patient wear shoes that have been made over a straight, or even an outflare, last. The patient can tolerate some arch support and inner wedge alterations if these are indicated, but the alignment of the shoe must necessarily conform with that of the foot to avoid pressure.

Toeing out in walking may result from tightness of the tendo achillis, in which case stretching of the plantar flexor muscles is indicated. (See p. 375 for stretching exercises.)

For correction of in-toeing. Anterior View Posterior View

For correction of out-toeing. Anterior View Posterior View

Tibial Torsion With Pronation

TWISTER

This elastic rotation leg control device, the Twister, is designed to exert a force of counter-rotation on the legs and feet to correct excessive internal or external rotation. This appliance is recommended for children with mild to moderate rotation problems and is frequently combined with other forms of treatment, such as shoe corrections and ankle braces. The simple fitting procedure of lacing the shoe hooks to the shoes, securing the pelvic belt with its Velcro fastener, extending the elastic straps as shown above, and adjusting the strap tension for the position desired produces an effective rotation control that usually requires only a short adjustment period by the patient. (Courtesy CD. Denison Orthopaedic Appliance Corp.) (14).

SHOES

The protection and support given by shoes are important considerations with regard to the postural alignment in standing. Various factors predispose toward faulty alignment and foot strain and create the need for adequate shoe support. The flat, unyielding floors and sidewalks of our environment, use of heels that decrease the stability of the foot, and prolonged periods of standing, as required in some occupations, are several of the causes contributing to foot problems.

A number of factors relating to the size, shape and construction of a shoe need to be considered.

Length: Overall length should be adequate for comfort and normal function.

Length from heel to ball: Feet vary in arch and toe length, with some having a longer arch and shorter toes and others a shorter arch and longer toes. No one special type of shoe is suited to all individuals. The shoe must fit with respect to arch length as well as overall length.

Width: A shoe that is too narrow cramps the foot. A shoe that is too wide fails to give proper support and may cause blisters by rubbing against the foot.

Width of heel cup: The shoe should fit snugly around the heel of the foot. Finding a shoe with a heel cup narrow enough in proportion to the rest of the shoe is often a problem.

Width of shank: The shank is the narrow part of the sole under the instep. The shank should not be too wide, but it should permit the contour of the leather upper part of the shoe to be molded around the contour of the arch of the foot. If the shank is too wide, the arch of the foot does not have the support given by the shoe counter.

Width of toe counter: The shoe needs to allow for good toe position and permit action of the toes in walking. The toe counter helps to give space to this part of the foot and keeps the pressure of the shoe off the toes.

Shape of Shoe: A normal foot should be able to assume a normal position in a properly fitted shoe. Any distortion in shape that tends to pull the foot out of good alignment is not desirable. A fairly common fault is that shoes flare in too much. This design is based on the assumption that strain on the long arch is relieved because it is raised by an inward twist of the forefoot. The foot of a growing child may conform to the abnormal shape if such shoes are worn for a period of years. Because an adult's foot is not as flexible as a child's and not as easily forced out of its usual alignment, a shoe with an inflare is likely to cause excessive pressure on the toes.

Heel Counter: A heel counter is a reinforcement made of stiff material that is inserted between the outer and inner layers of the leather that form the back of a shoe. It serves two purposes: to provide lateral support for the foot and to help preserve the shape of the shoe. As the height of the heel increases, the lateral stability of the foot decreases, and the counter becomes especially important for balance.

When the leather surrounding the heel is not reinforced, it will usually collapse after a short period of wear and shift laterally, in whatever direction the wearer habitually thrusts the weight. When this has happened, the feet can no longer be held in a good alignment by such shoes. (See photograph below.)

Shoes that have a cut-out back and depend on a strap to hold the heel in place offer even less stability than do shoes with enclosed heels and no counter. The shoe itself does not show as much deterioration with wear, however, both because the strap merely shifts sideward with the heel and because the shoe has no heel leather to break down. In flat-heeled shoes, the effect on the wearer may be minimal, but the lack of lateral support in a higher heel cannot persist indefinitely without some ill effects. These effects may be felt more at the knee than in the foot itself.

Strength of Shank: A good shank is of prime importance, both for the durability of the shoe itself and for the well-being of the person who wears it. When a shoe has a heel of any height, the part of the shoe under the instep is off the floor. The shank must then be an archlike support that bridges the space between the heel and the ball of the foot. If the shank is not strong enough, it will sag under a normal load when the shoe is worn. Such a sag permits a downward shift of the arch of the

Shoes Without Heel Counter

Shoes Without Stiff Heel Counters: The absence of a stiff counter in the heel allows the foot to deviate inward or outward. The shoe breaks down, and any existing fault tends to become more pronounced, as in the photograph above.

foot, and it tends to drive the toe and the heel of the shoe apart. The extreme of this type of deterioration in a flat-heeled shoe is sometimes seen in the rounded, rockerbottom shape that results (i.e., the shank being lower than the tip of the toe or the back of the heel).

A strip of steel reinforcing the shank provides the strength to preserve the shoe as well as to protect the wearer from foot strain. (See left figure, p. 446.) Both low- and high-heeled shoes require a strong shank. Fortunately, most high-heeled shoes are made with good shanks, but low-heeled shoes often are not. A prospective buyer can judge the shank of a shoe to some extent by placing the shoe on a firm surface and then pressing downward on the shank. If such moderate pressure makes it bend downward, it is safe to assume that it will break down under the weight of the body.

In heelless shoes, such as sandals and some tennis shoes, the firmness of the shank is of little importance for a person with no foot problems. Because the whole foot is supported by the floor or the ground, support from the shoe is not a major consideration unless the foot is being subjected to unusual strain from activity (e.g., in athletics) or from prolonged standing.

Sole and Heel of Shoe: Thickness and flexibility are the two important factors in judging the sole of a shoe. For prolonged standing, especially on hard floors made of wood, tile, or concrete, a thick sole of leather or rubber is desirable. This type of sole has some resiliency and is able to cushion the foot against the effects of the hard surface.

For people who are required to do a great deal of walking, a firm sole is desirable. The repeated movement of transferring weight across the ball of the foot in walking is a source of continuous strain. A firm sole that restricts an excessive bend at the junction of the toes with the ball of the foot guards against unnecessary strain. The sole should not be so stiff, however, that normal movement in walking in restricted.

When a child is learning to walk, the shoes should have no heel and a sole that is flat and firm enough to give stability. The sole should be fairly flexible, however, to allow proper development of the arch through walking.

The height of the heel is important in relation to the strain of the arches of the foot. Wearing a heel changes the distribution of body weight, shifting it forward. The proportion of weight that is born on the ball of the foot increases directly with the height of the heel. Continuous wearing of high heels eventually results in anterior foot strain.

The effects of a fairly high heel can be offset— though only to a limited degree—by using metatarsal pads and by wearing shoes that help to counteract the tendency of the foot to slide forward, toward the toe of the shoe. A shoe that laces at the instep or a pump with a high-cut vamp (preferably elasticized) helps to restrain the foot from sliding forward by providing an evenly distributed, uniform pressure—if the shoe fits well.

When the foot is allowed to slip forward in the shoe, the toes are wedged into too small a space and are subjected to considerable deforming pressure.

From the standpoint of normal growth and development as well as that of normal function, a person should use a well-constructed shoe with a low heel. Some individuals, however, especially women with a painful condition of the longitudinal arch, will benefit from wearing shoes with heels of medium height. In those cases, the higher heel mechanically increases the height of the longitudinal arch, and a flexible foot that is subject to longitudinal arch strain may be relieved of symptoms by using a heel approximately 1k inches high.

SHOE CORRECTIONS AND ORTHOSES

Because correction of faulty foot conditions largely depends on supports and shoe alterations, brief descriptions of some of these are pertinent to this discussion.

A heel wedge is a small piece of leather in the shape of half of the heel. It is usually applied between the leather or rubber heel lift and the heel proper. It is of a given thickness, usually V>6 to '/s inch at the side and tapering off to nothing at the midline of the heel. An Inner wedge

Metatarsal Bar Wedge Rockers

A = inner heel wedge; B = metatarsal supports; C = toe-out patch; D = metatarsal bar; E = metatarsal pads; F = longitudinal arch support (cookie); G = insole; H and I = rigid orthotic devices.

Metatarsal pad on the bones of the sole of the foot.

is so placed that the thickness appears on the inner side of the heel; this serves to tilt the shoe slightly outward. In an outer wedge, the thicker part is at the outer side of the heel and tends to tilt the shoe inward.

A sole wedge, made by cutting the sole in half lengthwise, may be used as an inner or an outer wedge.

A Thomas heel is a heel extended on the inner side for support of the medial longitudinal arch. A reverse Thomas heel is extended on the outer side for correction of a supinated foot.

A longitudinal arch support is a support put inside the shoe under the medial longitudinal arch of the foot. It is often made of firm rubber and leather. In many instances, however, a more rigid support is needed, and these devices need to be custom-made for each individual. Semirigid or rigid supports are fabricated from a neutral suspension cast that is designed to hold the subtalar joint in a neutral position while locking the midtarsal joint

A metatarsal pad is a small, firm rubber pad with an essentially triangular shape. It is placed proximal to the heads of the metatarsals, and it acts to reduce hyperextension of the metatarsophalangeal joints of the second, third, and fourth toes. To indicate the position of the support in relation to the foot and in relation to the shoe, a metatarsal pad was inserted in a shoe and a radiograph of the foot obtained with the shoe on (see figure, below).

A metatarsal bar is a strip of leather extending across the sole of the shoe. It acts to lift the metatarsals proximal to the heads, as does the pad, but it is more rigid and affects the position of all the toes rather than just the second, third, and fourth. (See D in figure, p. 445.)

A long counter is an extended counter that is added on the inner or outer side of the shoe.

The foot muscles cannot be expected to compensate for or correct a condition involving faulty bony alignment and ligamentous relaxation. Strong muscles will help to preserve good alignment, but supports are necessary to correct faulty alignment. The support should relieve strain on the muscles. For tight muscles that maintain a persistent faulty alignment of the foot or toes, stretching is indicated. Effective shoe corrections do much to bring about the gradual stretching of the tight muscle.

Normal use of the foot usually provides sufficient exercise for strengthening the muscles. Except among individuals who are bedridden or do very little walking, it is safe to assume that the average person does not lack exercise of the feet.

CORRECTIVE FOOT EXERCISES FOR PRONATED FEET

Lying on Back:

1. Curl the toes downward, and hold while pulling the foot upward and inward.

2. With the legs straight and together, try to touch the soles of the feet together.

Sitting in Chair:

3. With the left knee crossed over the right, move the left foot in a half-circle downward, inward, and upward, and then relax. (Do not turn the foot outward.) Repeat with the right foot.

4. With the knees apart, place the soles of the feet together and hold while bringing the knees together.

5. Place a towel on the floor. With the feet parallel and approximately 6 inches apart, grip the towel with the toes, and pull inward (in adduction) with both feet, bunching the towel between the feet.

6. With a small ball (~l '/4 to \ ' k inches in diameter) cut in half and placed under the anterior arch of the foot, grip the toes downward over the ball.

Standing:

7. With the feet straight ahead or slightly out-toeing, roll weight to the outer borders of the feet by pulling upward under the arches.

Walking:

8. Walk along a straight line on the floor, pointing the toes straight ahead and transferring weight from the heel along the outer border of the foot to the toes.

Apparent Limb Length Discrepancy
Radiograph of the foot in a shoe.

The habitual position of the knee in standing indicates which areas are subjected to undue pressure and which to undue tension. Symptoms of muscle and ligamentous strain are associated with the areas of undue tension, whereas symptoms of bony compression are related to (he areas of undue pressure. The postural faults may appear separately or in various combinations. For example, postural bowlegs results from the combination of hyperextension of the knees, medial rotation of the hips, and pronation of the feet. Medial rotation and slight knock-knee are frequently seen in combination. Lateral rotation is often seen with severe knock-knee. (See p. 82.)

This text does not deal with the treatment of congenital or acquired deformities of the feet and knees. An excellent reference for such treatment is found in the chapter by Joseph H. Kite in Basmajian's Therapeutic Exercise (best in the third edition) (IS).

BOWLEGS

In children, a position of bowlegs may be either actual or apparent (i.e., structural or postural). An actual bowing is of the shaft (femur, tibia, or both) and usually is caused by rickets. An apparent bowing occurs as a result of a combination of joint positions that permit faulty alignment without any structural defect in the long bones. It results from a combination of medial rotation of the hip, hyperextension of the knee joint, and pronation of the foot. (See pp. 81 and 82.)

Hyperextension alone does not result in a position of postural bowlegs; the medial rotation component is required. Medial rotation of the thigh plus pronation of the foot do not result in bowing unless accompanied by hyperextension. Thus, on testing, the apparent postural bowing will disappear in nonweight bearing or in standing if the knees are held in neutral extension.

Correction depends on use of appropriate shoe corrections, exercises to correct pronation, exercises to strengthen hip lateral rotators, and cooperation by the subject in avoiding a position of knee hyperextension.

In some instances, postural bowing and hyperextension are compensatory for knock-knees, as described on page 83. Paradoxically, correction of this type of postural bowing must be based on correction of the underlying knock-knee problem.

Correction of structural bowing depends chiefly on timely intervention and effective bracing. An outer wedge on the heel or sole usually is not indicated, because there is a tendency for the foot to pronate as the legs bow outward.

KNEE HYPEREXTENSION

Hyperextension of the knee joint results in undue compression anteriorly and undue tension on muscles and ligaments posteriorly. Pain may occur in either area. (See pp. 81 and 84.) Pain in the popliteal space is not uncommon in adults who have stood with the knees in hyperextension.

Hyperextension may cause further problems if not corrected. The popliteus is a short (one-joint) muscle that acts somewhat as a broad posterior knee joint ligament. Its action is to flex the knee and to rotate the leg medially on the thigh. (See p. 416.) If it is stretched by knee hyperextension, it allows the lower leg to rotate laterally on the femur in flexion or in hyperextension.

Prevention or correction of hyperextension is based on instruction in good postural alignment and cooperation by the subject in avoiding positions of knee hyperextension in standing. Specific exercises for knee flexors may be indicated. Bracing may be required in cases that do not respond otherwise and in severe cases.

KNOCK-KNEES

Tension on the medial ligaments and compression on the lateral surfaces of the knee joint are present in knock-knees. Discomfort and pain associated with the tension on the ligaments is annoying, but it is often tolerated for a long time before becoming incapacitating. The pain associated with compression, however, is slow to develop, but it is often intolerable when it first manifests itself. Evidence of arthritic changes may appear on radiographs.

Tightness of the tensor fasciae latae and iliotibial band is frequently seen in conjunction with knock-knees, even in young children. Heat, massage, and stretching of the muscle and fascia lata often are needed, along with shoe corrections to bring about a realignment.

In treatment of early, mild knock-knee, an inner border wedge on a shoe tends to realign the extremity, thus relieving the strain medially and the compression laterally. There is danger, however, in using too high an inner wedge, because overcorrection of the foot may be overcompensated for by an increase in knock-knee. A Vs- to 3/i6-inch inner heel wedge is usually adequate. A moderate degree of knock-knee may benefit from a knee support in addition to shoe corrections. The support should have lateral steel uprights, with a joint at the knee. Severe knock-knee requires bracing or surgery.

MEDIAL ROTATION OF HIP AND PRONATION OF FEET

The position of the knees in which the patellae face slightly inward results from medial rotation at the hip joints. As a functional or apparent (i.e., not structural) malalignment, it is usually accompanied by pronation of the feet (See p. 80.) The initial problem may be at the hip or at the foot, and it may result from weakness of the hip external rotators or of the muscles and ligaments that support the longitudinal arches of the feet Whichever predisposes to the fault, the end result is usually that both conditions exist if the initial problem is not corrected. A tight tensor fasciae latae may be a contributing cause, and sitting in a reverse tailor or "W" position may predispose toward faulty hip, knee, and foot positions. (See figure below.)

There may be a structural malalignment with a lateral tibial torsion accompanying the hip medial rotation. In either event, there tends to be pronation of the foot, but with tibial torsion, there is more out-toeing of the foot.

The malalignment affects the knee joint adversely, causing ligamentous strain anteromedially and joint compression laterally.

Treatment consists of shoe alterations and/or or-thoses that support the longitudinal arch, exercises for foot inverters (see foot exercises, p. 446), strengthening exercises for hip lateral rotators, and stretching of the tensor fasciae latae if tight (see pp. 398 and 450).

KNEE FLEXION

Tailor Position

Reverse tailor or "W" position.

Naturist Male Wrestling

Reverse tailor or "W" position.

Knee flexion is a less common finding than the three above-mentioned problems, but it is fairly common among older people. Habitually standing with the knees flexed (see figure p. 81) can cause problems at the knee and along the quadriceps muscle. It is a position that requires constant muscular effort to keep the knees from flexing further. Pain is most often associated with muscle strain of the quadriceps or with the effect of traction by the quadriceps (through its patellar tendon insertion) on the tibia.

Sometimes a position of knee flexion is assumed to ease a painful low back that is otherwise pulled into a lordotic curve by tight hip flexors. There may also be actual shortness of the popliteus and the one-joint hamstring, namely the short head of the biceps femoris. If the hip flexors and knee flexors are tight, institute appropriate stretching exercises are indicated.

Effect on Posture: Unilateral knee flexion creates concerns beyond the area of the knee. The effect on posture may be seen in the figures above. With the left knee flexed, the right foot is more pronated than the left, the right thigh is medially rotated, the pelvis tilts down on the left, the spine curves convexly toward the left, the right hip is high, and the right shoulder is low.

The conditions discussed here include pain associated with a tight tensor fasciae latae and iliotibial band, stretched tensor fasciae latae and iliotibial band, and sciatica associated with a protruded intervertebral disk or a stretched piriformis.

TIGHT TENSOR FASCIAE LATAE AND ILIOTIBIAL BAND

A condition sometimes mistakenly diagnosed as sciatica is that of pain associated with a tight tensor fasciae latae and iliotibial band. The dermatome area of cutaneous distribution corresponds closely with the area of pain.

Pain may be limited to the area covered by the fascia along the lateral surface of the thigh or it may extend upward over the buttocks, involving the gluteal fascia as well.

Palpation over the full length of the fascia lata, from its origin on the iliac crest to the insertion of the iliotib-ial band into the lateral condyle of the tibia, may elicit pain or tenderness. There is tenderness especially along the upper margin of the trochanter and at the point of insertion near the head of the tibia.

Painful symptoms may be limited to the area of the thigh or may appear in the area supplied by the peroneal nerve. A review of the anatomy of the lateral aspect of the knee shows the relationship of the peroneal nerve to the muscles and fascia in this area (see figure).

The peroneal branch of the sciatic nerve passes obliquely forward, over the neck of the fibula, and crosses directly under the fibers of origin of the per-oneus longus muscle. Any prolonged pressure over this area, even if only slight, must be avoided because of the danger of peroneal nerve paralysis. Even in the application of adhesive traction to the lower leg, one must avoid either pressure over the nerve or excessive traction on the soft tissue at that point.

The mechanism by which the peroneal nerve is irritated in cases of tightness of the iliotibial band may be explained by the effect of pressure by the rigid bands of fascia or by the effects of traction on this part. When the fascia is drawn taut, as in movements of walking or on testing for tightness, the fascia is often observed to be extremely rigid.

The effect of traction is often seen in acute cases. With the patient side-lying and the affected leg uppermost, the mere dropping of the foot into inversion (i.e., downward toward the table) puts tension on the muscle and fascial band. Symptoms of nerve irritation in the area supplied by the peroneal nerve may be elicited by this simple movement of the foot. When the side-lying position is assumed for sleeping or treatment and pillows are placed between the legs to keep the leg in abduction, the foot should also be supported to prevent it from dropping into inversion. Failure to recognize the

Common peroneal n

Peroneus fongus

Superficial peroneal

Deep peroneal n

Common peroneal n

Peroneus fongus

Superficial peroneal

Deep peroneal n

- Biceps femoris

~ Tibialis anterior Exi. digit, longus

Ext. ballucis longus

- Biceps femoris

~ Tibialis anterior Exi. digit, longus

Ext. ballucis longus peripheral cause of this peroneal nerve irritation has often resulted in rather obscure explanations of this problem.

Tightness of the tensor fasciae latae and iliotibial band may be bilateral or unilateral, but when tightness is marked, it is more often unilateral. Activities such as skating, skiing, or horseback riding may contribute to bilateral tightness.

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