limp

The title of this article is ambiguous. For the German engineer, electrical engineer, university professor and entrepreneur, see Johann Hinken .

limp

Limping (out of date also lame ; Latin claudication , from claudicare , "limp") is a form of unilateral or bilateral gait disorder , an asymmetry of the gait in its distance and time factors. Due to the disturbed pelvic-leg statics, the gait appears abnormal and pathologically changed. When walking, the change between stance and swing phase is disturbed. The ability to walk is retained, but may be restricted. When you limp on both sides (lat. Vacillatio , claudicatio anatica ), the pelvis tilts to the side with every step.

The limp can be temporary or permanent. Depending on the cause, it is divided into different forms, with mixed forms often occurring:

• Foreshortening limbs
• Painful limp
• Stiffening limbs
• Paralysis limp
• the limp in static and dynamic instability
• Limping in neuromuscular coordination disorders
• Trendelenburg limp (hip limb)
• intermittent limping
• psychogenic limping

General characteristics when limping

Two-legged walking in particular is characterized by coordinated vibrations of the various parts of the body, both in normal and in limping gait. In this kinematic chain, the trunk and upper extremities (arm pendulum) move along. The pendulum behavior of the individual parts, in the sense of counter-holder mechanisms, is important for the harmonious course of the corridor as an energy-saving movement.

With one-sided limping, the symmetry of the step pattern is disturbed and the result is an uneven step size or an abnormal step rhythm. With this form of walking, the sequence of steps is not uniform and regular, the result is an inharmonious asymmetrical gait pattern, the sequence of movements and step length are no longer symmetrical, and the weight distribution deviates from the norm. One leg is faster than the other leg when walking.

In 1967, Mary Murray described in detail the space / time parameters of the gait of hip patients when they limp:

• reduced walking speed,
• extended duration of the double stance phase
• extended stance phase duration of the healthy leg
• increased movements of the trunk and head
• Reduced stride length when the affected leg begins the stride cycle (extension inhibition)
• increased pelvic movement
• reduced movement in both the hips and knees
• increased elbow flexion also in the swing phase
• decreased cadence
• Shifting the upper body to the standing side

Modern methods for gait analysis are:

• Film recordings in three levels
• Chronocyclography ( multiple exposure photography )
• Light trail recordings
• Measurement of ground contact and the force applied to the ground
• Registration of joint position, speed and acceleration of the body parts
• Measurement of muscle activity while walking ( electromyography )

Foreshortening limbs

The shortening limp is caused by anatomical or functional leg shortening and is accompanied by a misalignment of the pelvis. The triggering causes are differences in leg length , one-sided shortening of the muscles responsible for knee and hip flexion, or shortened adductors . The shortenings can be in the joint or peripheral part of a leg.

The foreshortening limp can be the first symptom of a leg length discrepancy or a one-sided misalignment, e.g. B. Genu varum malposition.

Such unilateral leg shortening occurs, for example, in osteoarthritis of the hip , hip dysplasia or as a result of poliomyelitis . Even after femoral neck fractures that have not properly healed, leg shortening can occur as a result of a varus malalignment of the femoral neck .

A hip flexion contracture or a hip spread contracture leads to functional leg shortening, while a hip spread contracture leads to a functional leg lengthening. The shortened limp is only noticeable when walking, but not when standing on one leg (pelvic position). With shortened limping, the body's center of gravity drops excessively while walking, during the short stance phase on the shortened leg, and the body's center of gravity is shifted over the relatively longer supporting leg to compensate for weight .

An equinus foot leads to functional lengthening of the leg and thus to a shortened limp. Congenital clubfoot or past poliomyelitis lead to shortening limps according to the same mechanism . In order to compensate for the shortened limb, the affected persons try to make the leg lengths of both sides equal. To do this, walk with the shorter leg in the toe position or with the longer leg with the knee and hip joint slightly bent; both compensation mechanisms can also be used at the same time.

Treatment of the shortening limb

The aim of the treatment is to compensate for the leg lengths by means of surgical leg lengthening , which can be done up to 20 cm, or to raise the shoes ( orthopedic shoemaker ; leg lengthening compensation for walking and standing). Compensation with orthopedic shoes, however, often leads to functional and cosmetic impairments. In naturopathy , manual leg length compensation is also propagated, with treatment concentrating on the longer leg, which is usually identified as the pathologically elongated one.

Surgical methods of leg lengthening include:

• External fixator (external tensioner) for callus distraction (obsolete)
• Extension intramedullary nail (extension nail), the intramedullary nail is inserted into the bone and no external screws and nails are seen
  • ISKD nail (Intramedullary Skeletal Kinetic Distractor, internally mechanical, i.e. the intramedullary nail is pulled apart a few millimeters by rotating the leg)
  • Albizzia nail (internal mechanical)
  • Fitbone (internally electrical, i.e. the intramedullary nail is driven by an internal motor and moves a few millimeters apart)
• Total Endo-Prosthesis (TEP)

Painful limp

The so-called painful limp or slow limp is the result of painful illnesses or trauma to the leg (e.g. knee joint), foot (e.g. ankle or Achilles tendon ), hip or sacroiliac joints . Unilateral hip pain can be caused, for example, by bruises , coxitis (hip joint inflammation), femoral head necrosis or hip arthrosis.

Due to the only short-term careful loading of the aching standing leg due to the stress pain, an asymmetrical (irregular) gait pattern is shown in order to protect a leg by relieving weight ( relieving posture by relieving limbs with a shortened standing leg phase on the diseased leg; painful appearance), with this then the step becomes carried out faster in order to shorten the load time or to only partially load the painful leg (partial load). In some cases, the foot is only partially or not at all rolled to reduce pain . For example, if the Achilles tendon complains, it is no longer possible to forcefully roll the foot and toes. The pushing off of the foot from the ground is slowed down in order to avoid peak loads. Especially in the case of only slight pain or pain on both sides, the foot may simply be placed carefully and slowly on the floor. Possibly only painful parts of the walking movement are shortened - e.g. B. with osteoarthritis of the metatarsophalangeal joint of the big toe or hallux rigidus .

In order to reduce the torque of the hip abductors by shortening the load arm, the upper body and thus the body's center of gravity is shifted over the supporting leg when limping pain. The movement of the pelvis and thighs occurs when the pain is limped by tilting the lumbar spine. Such causes of pain can be tendon strains, injuries or age-related wear and tear of the joints, but also unsuitable footwear.

The concept of pain avoidance claudication (Engl. Antalgic gait ) was in 1939 by Jacques Calvé coined when he limping with hip pain ( Coxalgien described).

Stiffening limbs

In the case of stiffened limping, hip stiffening, i.e. restriction of movement in the hip joint, is responsible for the pelvic movement during the swing phase of the gait. In contrast to other types of limping, the pelvis does not sink. Due to the stiffening in the hip joint, the leg cannot swing forward freely while walking, but the leg swing forward by rotating the entire pelvis. The body's center of gravity may also be raised by slightly standing on the toes on the healthy side.

Stiffening of the knee or ankle also results in a limping gait. In the event of stiffening in the knee joint, the hip joint is raised sharply to compensate for it and then the leg is swung forward in a lateral outer curve (circumduction). If the ankles stiffen, the stepping and rolling is disturbed.

Paralytic limp

The paralytic limp occurs in partial or total flaccid paralysis . Instead of paralyzed limping, the term "limping in spastic paralysis and coordination disorders" is also used. Paralytic limping also includes spastic gait disorders, for which the consequences of polio or certain spinal cord lesions can be the cause, as well as paretic gait disorders due to incomplete paralysis of peripheral nerves. Another form of paralyzed limping is the stepper gait , which is usually caused by peroneal paralysis (paralysis of the foot lifter). Here, the ball of the big toe is placed before the heel. In the case of paralyzed limbs, compensatory increased action of other muscle groups often occurs.

Hip limb

The hip limp occurs when the middle gluteal muscles ( musculus gluteus medius ) and the small gluteal muscles ( musculus gluteus minimus ) are insufficient ( limp insufficiency). As a result, the pelvis sinks to the opposite side in the standing leg phase, while at the same time tilting the trunk to the side (affected). With hip limps or insufficiency limps, there is a static or dynamic instability of the pelvis (anatomy) . The hip limp is also known as the Trendelenburg gait, Trendelenburg limp, Duchenne limp or Trendelenburg-Duchenne limp. It is triggered by weakness or paralysis of the thigh abductors .

Diagnosis of the hip limb

With the Trendelenburg limp , in the short phase of standing on one leg on the affected leg, the pelvis tilts onto the unaffected side of the swing leg. The reason for this is a severe insufficiency of the thigh abductors. These keep the pelvis in a horizontal position in healthy people during the one-legged stance phase. Since the tilting of the pelvis is difficult to detect without technical aids to record the Trendelenburg limp, the doctor uses the diagnosis of the patient while standing. The Trendelenburg sign while standing is the static equivalent for the Trendelenburg limping while walking (dynamic examination). The Trendelenburg sign is positive if the healthy side of the leg sinks when standing on the diseased leg (one-legged stance), the patient lifting the healthy leg, which is bent at the hip and knee, a little. In other words: the Trendelenburg sign is positive if the hip on the swing side is not raised; or: when exercising, the pelvis sinks to the opposite side. In contrast, when standing on the unaffected leg, the pelvis can be kept in a horizontal position. The sinking of the pelvis when standing on the affected side indicates weakness in the gluteus medius and gluteus minimus muscles.

Friedrich Trendelenburg found in 1895 that the gluteus medius muscle is the most important muscle whose weakness triggers the hip limp.

As early as 1865, Guillaume-Benjamin Duchenne described the hip limp in a comparative study between the forms of the limp in the case of a weak abductor and the limp in the case of paralysis. When standing on one leg on the affected leg, the upper body is shifted to the side of the standing leg. Although Duchenne described the hip limp ten years before Trendelenburg, the Duchenne sign named after him (upper body lateral inclination) refers to a compensatory follow-up to the Trendelenburg sign (tilting of the pelvis). Or to put it another way: To avoid tilting the pelvis to the side of the swing leg (Trendelenburg sign), the center of gravity is shifted slightly by leaning the body over (Duchenne sign). However, this only occurs when standing on one leg on the affected side. The dynamic equivalent of the (static) Duchenne sign is the Duchenne limping (Duchenne gait): When walking, there is an increased displacement of the trunk to the affected side of the standing leg in order to compensate for the hip abductor insufficiency. A positive Duchenne sign (upper body side tilt) can compensate for a weak Trendelenburg sign and thus mask it and leave it undetected. The Trendelenburg sign is prevented by the torso leaning to the side to the affected side when under stress.

In 1939 Calvé differentiated between (pain-related) analgic hip limping and limping due to gluteus medius insufficiency. The muscle strength required for walking is reduced by the hip limb, consequently only less force has to act on the hip joint when walking and a painful joint is spared (pain-related hip limb).

Causes of the hip limp

The reason for the muscle insufficiency (disorder of muscle-gluteus function) are hip joint diseases, such as childhood hip dysplasia (flattening of the acetabulum), hip dislocation or coxa vara (shortened femoral neck angle), nonunion, muscular dystrophy, coxa vara (Schenkelhalsverbiegung with Fehlinsertion the muscles and thus unfavorable lever arm ; e.g. if the trochanter is elevated). Since this muscle insufficiency often occurs on both sides, it then comes to a bilateral limp. Trochanteric dislocation is a possible therapy of choice for hip limping.

Thigh abductors

The thigh abductors (leg spreader) cause the leg to spread out ( abduction ). It is correct to speak of hip abductors instead of thigh abductors. The following muscles belong to this muscle group:

• Gluteus medius muscle
• Gluteus minimus muscle
• Gluteus maximus muscle (cranial part)
• Tensor fasciae latae muscle
• Piriformis muscle
• Sartorius muscle

Of these muscles, only the latter, the sartorius muscle , belongs to the thigh muscles . The first five muscles belong to the back or deep layer of the hip muscles . When walking and running, the leg abductors ensure that the pelvis is balanced with every step. The main thigh abductors are the gluteus medius muscle and the gluteus minimus muscle , while the gluteus maximus muscle and the tensor fasciae latae muscle only have an additional effect. Since the lever arm of the body load is about three times as long as the lever arm of the abductors when standing, their muscle strength when standing on one leg must be about three times the body weight.

Hip limb in hip arthrosis

The limp in hip osteoarthritis is a slight, shortening or hip limp. With osteoarthritis of the hip (coxarthrosis), the thigh abductors can be weakened for two reasons:

1. Approach of the origin and insertion of the respective muscle (anatomical cause)
2. reflex inhibition due to pain (functional cause)

Intermittent limping

Main article: Intermittent claudication

Intermittent limping (from Latin intermittens , "temporarily") can occur on the basis of arterial occlusive disease: as a result of arterial circulatory disorders ( peripheral arterial occlusive disease ), which then lead to cramp-like calf pain and trigger the limp. From intermittent claudication the much rarer is intermittent claudication spinal distinguish. The pain and the accompanying limp as a result of a spinal stenosis typically occur when walking up and down and subside when walking pauses. Also a circulatory disorder of the intestinal wall - in angina abdominalis an intermittent limp can trigger, the intermittent claudication .

Psychogenic limping

Psychogenic limp triggers are primarily psychological factors. It is a painless, "voluntary" limp.

Individual evidence

1. ↑ Hans-Ulrich Debrunner, Wolfgang Rüdiger Hepp: Orthopädisches Diagnostikum. 7th edition. Thieme, Stuttgart 2004, ISBN 3-13-324007-2 .
2. ^ Mary Pat Murray: Gait as a total pattern of movement. In: American Journal of physical medicine. (1967); 46/1, pp. 290-333.
3. ↑ A. Handlbauer, R. Suda, R. Ganger, F. Grill: Leg length differences and axial misalignments: intramedullary extension nail as an alternative to external fixation? ( Memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
4. ^ Jacques Calvé, Marcel Galland, Roger de Cagny: Pathogenesis of the limp due to coxalgia. In: Journal of Bone and Joint Surgery. 1939; 21, pp. 12-25.
5. ^ Friedrich Trendelenburg: About the gait with congenital hip dislocation. German Medical Weekly No. 2, year 1895, pp. 21-24.
6. ^ GB Duchenne: Physiology of movements after electrical experiments and clinical observations with applications to the study of paralysis and disfigurement. translated by Dr. C. Wernicke. Fischer, Cassel / Berlin 1885, pp. 322-332.
7. ^ Jacques Calvé, Marcel Galland, Roger de Cagny: Pathogenesis of the limp due to coxalgia. In: The Journal of Bone and Joint Surgery. 1939; 21, pp. 12-25.
8. ^ Helmut Rössler, Wolfgang Rüther: Orthopedics and trauma surgery. 19th edition. Elsevier, Munich 2005, ISBN 3-437-44445-X .

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