Why does steppage occur?
Peroneal nerve neuropathy
Along with the cock's gait, this pathology is characterized by the impossibility or difficulty of standing and walking on the heels, and raising the outer edge of the sole. Sensory disturbances are detected on the back of the foot and in the lower part of the lower leg. The muscles on the anterior outer surface of the leg and the back of the foot atrophy over time, so the affected leg looks thinner in the lower leg, with sunken interosseous spaces on the foot. The causes of neuropathy are:
- Traumatic injuries
: injuries to the knee joint and shin bones, tears and ruptures of the ankle ligaments. - Iatrogenic injuries
: accidental disruption of nerve integrity during knee and ankle surgery and ankle repositioning. - Vascular pathologies
: atherosclerosis of the vessels of the lower extremities, obliterating endarteritis. - Local growths of connective tissue
: arthrosis deformans, rheumatoid arthritis, scleroderma, dermatomyositis. - Spinal diseases
: osteochondrosis, disc herniation, spondyloarthrosis, spondylolisthesis.
A frequent provoking factor for neuropathy with the development of stepping is compression of the nerve in the foot or head of the fibula due to prolonged exposure to a forced position in representatives of certain professions. In addition, nerve compression is sometimes observed during immobilization. A rare cause of neuropathy is a tumor in the area of the nerve.
Polyneuropathy
With polyneuropathies, not one leg is affected, but both, and weakness of the hands is revealed. Stepping is not observed in all patients; it develops with significant weakness of the peroneal muscles. The severity of motor, sensory and autonomic disorders varies. A feature of many polyneuropathies is the asymmetry of the cock's gait and other motor disorders with the symmetry of autonomic and sensory symptoms. Taking into account the etiology, the following multiple nerve lesions are distinguished:
- Hereditary
: Refsum's disease, Roussy-Levi syndrome, neural amyotrophy of Charcot-Marie-Tooth. - Metabolic
: for diabetes, liver and kidney failure. - Autoimmune
: paraproteinemic, with paraneoplastic syndrome.
In addition, polyneuropathies develop during acute and chronic intoxication. The most common example of toxic nerve damage is alcoholic polyneuropathy. Multiple nerve damage is detected in some infectious diseases, sometimes detected during pregnancy.
Neuropathies
Multiple sclerosis
The disease often begins with weakness in the legs; in some patients, a cock's gait develops even in the early stages of the disease. Subsequently, the severity of stepping varies depending on the phase of the disease. Numbness and paresthesia in different parts of the body, optic neuritis, dizziness, and dysfunction of the pelvic organs are possible. Then paresis and cerebellar disorders occupy a central place in the clinical picture.
Polio
Cock gait occurs with spinal and mixed forms of poliomyelitis, develops on the 3-6th day of illness, and is not an obligatory symptom. In most cases, stepping is unilateral in nature and is combined with paresis and paralysis of other muscle groups. The outcome may be complete or partial disappearance of symptoms. In some patients, cock gait and other disturbances persist throughout their lives.
Guillain-Barre syndrome
Guillain-Barré syndrome manifests itself with sensory disturbances and muscle weakness in the lower extremities. The consequence of muscle weakness is a rooster-like gait. Manifestations progress rapidly, and neurological disorders spread to the upper extremities. The severity of symptoms ranges from minor muscle weakness to complete tetraparesis. Respiratory failure occurs in 30% of patients.
Movements in the joints using the example of the ankle and foot
Greetings, dear colleagues!
In one of the previous articles, we examined axes and planes.
And in this article we’ll talk about the movements that joints make along axes in the planes of the human body.
This knowledge will help you better understand the material that is given in various fitness trainings.
To avoid confusion (the names of the axes and planes are the same), I recommend re-reading the article on anatomical terms.
So, movements around all three axes are possible in the joints:
- around the frontal (transverse) axis: flexion ( flexio ) and extension ( extensio ).
- around a vertical axis: rotation ( rotatio ); outward rotation ( supinatio ) and inward rotation ( pronatio ).
Based on the “standard” anatomical position, i.e. palms are directed forward, pronation will be turning the palm back, i.e. movement of the hand around a vertical axis, in which the thumb and index finger move forward in a circle towards the body (into a handshake position).
Supination , respectively, is the opposite, turning the palm forward.
Medical students use the mnemonic: I pour SOUP, SPILL SOUP.
Indeed, supination is a “scooping” movement of a spoon from a plate, and pronation is a “plunging” movement of a spoon into a plate.
It is important to note that torsion refers to intraosseous changes, incl. twisting, during growth. All other processes, incl. active movement is rotation.
- Around the sagittal axis: abduction ( abductio ) and adduction ( adductio ).
- In some joints (biaxial and triaxial), circular motion ( circumductio ) is possible, in which the moving part of the body describes a cone.
The greatest difficulties in designating movements arise in the joints of the legs.
Movements at the ankle joint
(articulatio talocruralis, articulatio - joint, talus - talus, crus - tibia)
The ankle joint is capable of flexion and extension.
Moreover, flexion is considered to be lowering the sole, which is performed by the triceps surae and not only. Therefore, in functional anatomy this movement is called plantar flexion (planta).
Abduction and adduction of the ankle are possible with full plantar flexion.
Extension, accordingly, is the raising of the rear of the foot upward, and dorsiflexion (dorsal flexion) of the ankle joint, familiar to everyone from functional anatomy, from the point of view of “standard” anatomy is nothing more than its extension.
Foot movements
The greatest disagreement between authors and instructors-methodologists arises regarding the name of the movement in the foot as a whole (mainly due to the ankle and shopard joints) around the vertical axis - external / internal rotation - inversion / eversion or supination / pronation .
In the foot as a whole, movements around all axes are possible, and on their basis, combined three-plane movements arise. Due to the disagreements mentioned above, there is no single classification, and both options will be given below.
Option 1 (see table).
In my opinion, it is more logical from the point of view of “standard” anatomy, and it is precisely this that can be heard from the lips of Dmitry Gorkovsky in the “Body Architecture” course (or in the Prehab )
In the block on working with the foot, Dmitry explains why adduction is never combined with pronation, and abduction is never combined with supination.
Latin equivalents ( m. – musculus – muscle; mm. – musculi – muscles ):
- triceps surae muscle - m. triceps surae :
- gastrocnemius muscle – m. gactrocnemius ;
- soleus muscle – m. soleus ;
— anterior and posterior tibial muscles – mm. tibiales anterior et posterior ;
- long flexor and extensor fingers - mm. flexor et extensor digitorum longi ;
- long flexor and extensor of the big toe (hallux) - mm. flexor et extensor hallucis longi ;
- long, short, third peroneal muscles - mm. peronei longus, brevis, tertius .
Option 2. Among the famous instructors-methodologists, it is taught by Kirill Shlykov (“School of Podiatry”) and it is spoken by Georgy Temichev in the “
Prehab ”
. If we use this terminology: adduction is never combined with eversion, and abduction is never combined with inversion.
Colleagues refer to different authors, different sources, and there is no right/wrong here.
However, after reading this note, I think the meaning of the terms has become clearer to you:
- overpronation of the foot - what is commonly called flat feet;
- inversion foot injury - “twist”;
- instep support – a component of an orthopedic insole/shoe (elevation on the medial side), etc.
Professional terminology will allow you to communicate with colleagues in a language that everyone understands, without having to explain every time what you meant.
A competent trainer or doctor will always understand what you are talking about when you use the term eversion or inversion.
Just as you will understand the doctor’s recommendations or the story of a fellow trainer using professional terminology.
Author: neurologist Nikolai Votchitsev
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Diagnostics
A neurologist is involved in determining the cause of steppage formation. At the initial stage, the specialist clarifies complaints, collects anamnesis, and examines the dynamics of the appearance and development of symptoms. Then the doctor assesses the general condition of the patient. A special examination of a patient with signs of cock gait includes the following diagnostic techniques:
- Neurological examination
. Provides a detailed study of the motor and sensory sphere of the affected area or areas. During the examination, reflexes are determined, tests are performed to assess muscle strength, and special tests are performed to study the sensory sphere. - Electrophysiological methods
. In the process of electroneurography and electromyography, the speed of conduction of electrical potentials is assessed, which makes it possible to clarify the level and extent of nerve damage. The study of evoked potentials provides an opportunity to confirm the involvement of various afferent systems in multiple sclerosis. - Ultrasound of the nerve.
Recommended for mononeuropathies. Confirms the presence of scars and connective tissue growths causing compression of the nerve. - Radiography
. X-ray examination of the lower leg, knee or ankle joint is indicated for traumatic genesis of damage to the nerve trunk. - MRI of the brain.
The technique is necessary if multiple sclerosis is suspected; it is used to detect and determine the location of foci of demyelination. - Lab tests
. Tests for diabetes mellitus, studying liver and kidney function, identifying specific antibodies help differentiate polyneuropathies of various origins. Comprehensive general clinical examinations are informative in diagnosing Guillain-Barré syndrome. For polio, tests are done to detect the virus.
Neurological examination
Causes and symptoms
Foot paresis is called “slap foot,” “flapping foot,” or “drop foot.” The cause of this condition is damage to the root of the fifth lumbar spinal nerve, which is responsible for the innervation of the extensor muscles of the foot. Patients with foot paresis feel better in boots or hard high boots that do not allow the foot to sag. Walking in heels is problematic. Often patients are forced to use a stick. Inconveniences arise when getting into a car and walking up stairs.
Foot paresis with damage to the root of the first sacral spinal nerve may manifest itself somewhat differently. Patients cannot stand on their toes. They walk, leaning on their sore leg, and it is difficult for them to press the pedals of the car.
The cause of such conditions in most cases is a herniated lumbar intervertebral disc, which causes compression and partial or even complete death of the roots. At the Yusupov Hospital, the cause of foot paresis is determined using magnetic resonance imaging. The study is performed using modern tomographs from leading global manufacturers.
Benign positional paresis of the foot develops when sitting with legs crossed. It disappears immediately after changing posture or walking. Diabetes mellitus, which is the cause of diabetic polyneuropathy, can lead to foot paresis without prior pain. Drop foot develops when the patient has alcoholic neuropathy or a lower leg injury. Doctors at the Yusupov Hospital can easily establish these causes of foot paresis using magnetic resonance imaging, which does not reveal intervertebral disc herniation or compression of the spinal cord roots.
Treatment
Conservative therapy
The drug treatment regimen for diseases accompanied by the development of cock gait may include drugs from the following groups:
- NSAIDs
. Used for neuropathies and polyneuropathies. They have anti-edematous, analgesic and anti-inflammatory effects. Helps reduce the severity of symptoms. - Acetylcholinesterase inhibitors
. Indicated for patients with polyneuropathy, neuritis, multiple sclerosis. Improves neuromuscular transmission, stimulates the conduction of excitation along nerve fibers. - Hormonal agents
. Recommended for patients with multiple sclerosis. Treatment is carried out within the framework of pulse therapy followed by a gradual dose reduction. - Immunomodulators and immunosuppressants
. They stabilize the course of multiple sclerosis and prevent the transition of the remitting form to the progressive form. - Other drugs
. It is possible to use antidepressants, central nervous system stimulants, B vitamins, anticonvulsants, and medications to improve blood circulation.
For secondary lesions, treatment of the underlying pathology is necessary. For progressive generalized neurological disorders, resuscitation measures and mechanical ventilation are performed. Drug therapy for steppage is supplemented with non-drug methods. Exercise therapy, massage, and manual therapy are used. Electromyostimulation, paraffin treatment, and electrophoresis are prescribed. Patients are referred for magnetic therapy, amplipulse therapy, and ultraphonophoresis.
Foot placement: flat feet, pronation and supination
Correct foot placement also affects stability. It depends on the presence or absence of flat feet, pronation and supination.
Flat feet. The arch of the foot acts as a spring - responsible for balance and shock absorption when walking and running.
If the arch of the foot has become flat, the body transfers the function of springs to the joints of the legs and spine, which are not intended for this and can hurt.
Flat feet can be longitudinal, transverse and longitudinal-transverse. It also varies in degrees. With the first (mild) you can live peacefully and not even know about it.
The average can make itself felt, especially under load.
The third degree is the most difficult. It’s hard to even walk with such flat feet.
The cause of 8 out of 10 cases of flat feet is weak muscles of the foot and lower leg. In the absence of loads, they do not train and weaken. But flat feet can also appear from excessive stress: for example, standing work or constant training.
Pronation. This is the natural inward tilt of the foot. When moving, the arch of the foot flattens, coming into contact with a hard surface, and takes the load on itself. By pronating, the body absorbs the impact of placing the foot on the ground and maintains balance on uneven surfaces.
Supination. This is a process in which the movement of the foot is outward. Supination turns the foot into a rigid lever so that the leg can support the entire body. In addition, supination plays a role during the active phase of the push, giving a clearly directed forward movement.
There may be too much roll of the foot inward (overpronation) or outward (hypopronation). Overpronation is the most common condition. Its causes may be flat feet, weak muscles of the feet and legs.
However, the presence of overpronation does not always automatically mean flat feet. And vice versa. For example, a person with a flat foot may have well-developed muscles that ensure normal pronation. Or a person without flat feet may have a foot rolled inward due to weak muscles.