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CASE REPORT

Editor’s Note: Corrections to this article were published in the March 2010 issue of JAOA—The Journal of the American Osteopathic Association (2010;110[3]:210). The corrections have been incorporated in this online version of the article, which was posted January 2011. An explanation of these changes is available at http://www.jaoa .org/cgi/content /full/110/3/210-a.

Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction
Adam C. Gilliss, DO; Randel L. Swanson, II, OMS III; Deanna Janora, MD; and Venkat Venkataraman, PhD

Gait dysfunctions are commonly encountered in the primary care setting. Compensated Trendelenburg gait is a gait dysfunction that was originally described in patients with weakness of ipsilateral hip abduction. This condition is thought to result from neuronal injury or myopathy. No treatment modalities currently exist for compensated Trendelenburg gait. The authors present a case in which osteopathic manipulative treatment may have improved a Trendelenburg gait dysfunction in a man aged 65 years with multiple sclerosis. Evidence of this improvement was obtained with the GaitMat II system for measuring numerous gait parameters. Based on the results reported in the present case, the authors propose that compensated Trendelenburg gait may arise from somatic dysfunction and may be corrected by osteopathic manipulative treatment.
[Published correction appears in J Am Osteopath Assoc. 2010;110(3):210.] J Am Osteopath Assoc. 2010;110(2):81-86

In the present case report, we provide evidence that compensated Trendelenburg gait may represent a secondary gait dysfunction stemming from somatic dysfunction of the sacroiliac joints. We also describe evidence of osteopathic manipulative treatment (OMT) resulting in quantitative improvements in the gait cycle.

Traditional and Osteopathic Gait Theory
The gait cycle is divided into two main phases—stance and swing, each consisting of numerous subphases.2,3 Traditionally, the human gait cycle is considered to have six determinants that function independently, yet simultaneously, to generate the normally fluid, continuous movements of ambulation.4 The first two determinants of the gait cycle—pelvic rotation and pelvic tilt—involve the pelvis, including the right and left innominate bones and the sacrum. During the swing phase of the gait cycle, the pelvis rotates forward on the side of the swinging leg about a transverse plane, with the hip joint of the stance leg serving as the axis of rotation. In addition to this forward rotation, Trendelenburg tilt occurs on the side of the swinging leg, with the pelvis dropping by approximately 5 degrees.2 The degree of tilt is limited by contraction of the hip abductor muscles of the stance limb, primarily the gluteus medius. Also during Trendelenburg tilt, there is a lateral shift of the pelvis toward the stance leg, resulting in a shift in the center of gravity.2 In traditional gait theory, the pelvis is thought to function and move as a single unit, with the individual components immobile relative to one another.2,4 Osteopathic theory, however, holds that individual motions occur between the right and left innominate bones and the sacrum.5-7 These individual motions arise when torsion forces are created within the pelvis during the gait cycle, leading to variations in the timing of rotation, tilt, and lateral shift between the sacrum and innominates. Studies have documented the range of motion and the degree of rotation in these bones.8,9 Thus, clinical gait analysis must incorporate both traditional and osteopathic gait theory to arrive at the correct diagnosis. Physicians typically rely on visual observation alone to assess both normal and pathologic gait. Gait disturbances may arise from pathologic conditions of the spinal cord and lower body, as well as from cognitive and neurologic disorders of the brain.10-12 Gait analysis systems, such as GaitMat II (EQ Inc, Chalfont, Pennsylvania), are now available for making reliable
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hysicians routinely encounter gait dysfunctions in the primary care setting. Abnormal gait patterns have many causes and may represent either a primary or secondary (ie, compensatory) gait dysfunction. Compensated Trendelenburg gait, also known as compensated gluteus medius gait, was originally described in the late 1800s by German surgeon Friedrich Trendelenburg in patients with weakness of ipsilateral hip abduction.1 This weakness is thought to typically result from injury to the superior gluteal nerve or from a pathologic condition affecting proximal hip abductor muscles, primarily the gluteus medius. Currently, no treatment modalities exist for patients with compensated Trendelenburg gait.

From the Department of Osteopathic Manipulative Medicine (Dr Gilliss) and the Department of Cell Biology (Student Doctor Swanson and Dr Venkataraman) at the University of Medicine and Dentistry of New JerseySchool of Osteopathic Medicine in Stratford; and the JFK Johnson Rehabilitation Institute (Dr Janora) at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in Edison. This study was supported by intramural grants from the Osteopathic Heritage Foundations (V.V., R.L.S.). Financial Disclosures: None reported. Address correspondence to Adam C. Gilliss, DO, 27 E Chestnut Ave, Merchantville, NJ 08109-2504. E-mail: acgilliss@comcast.net Submitted August 22, 2008; final revision received April 13, 2009; accepted April 22, 2009. Gilliss et al • Case Report

California) and were repeated with SigmaStat (version 4. he was treated with standard medications for multiple sclerosis. Washington) software. these patterns arise from the collective motions of the individual musculoskeletal components that contribute to bipedal locomotion. the GaitMat II analysis and video recording 82 • JAOA • Vol 110 • No 2 • February 2010 OMT Application Osteopathic manipulative treatment was administered to the patient in each of the two trials. stance time. This treatment has continued to the present day. For the right-on-right sacral torsion and the posterior rotation of the left innominate.5 mg daily) for benign prostatic hyperplasia.16-18 Gilliss et al • Case Report . The patient’s surgical history was unremarkable. The sacroiliac diagnoses in both trials were right-onright sacral torsion and posterior rotation of the left innominate. We used GaitMat II in the present case report to evaluate a patient with Trendelenburg gait before and after OMT. Report of Case A man aged 65 years with a history of relapsing and remitting multiple sclerosis presented to the office of an osteopathic physician (A.13 are increasingly used in the clinical setting. in addition to other somatic dysfunctions throughout the body. intramuscular.13 (Weekly OMT sessions occurred between these two appointments as part of the patient’s regular treatment. From 1991 to 1999. California) and Excel (Office Professional 2007. Redmond. once weekly). Based on this video. and velocity were recorded for the left and right sides. Microsoft Corp. the patient was treated with standard OMT muscle energy techniques. Biomechanical examination of the patient during the OMT sessions revealed somatic dysfunction within the sacroiliac joints. trials)—one in September 2006 and the other 1 month later. we focus on two OMT sessions conducted in September and October 2006. occurred once before and once after OMT was administered by the osteopathic physician.J.14-15 Although the GaitMat II system measures only foot contact patterns recorded on the mat. number of steps. Medications used by the patient at the time of the present study included vitamin B12 injections (1000 ␮g. typically the distance from the heel of one foot to the heel of the same foot where it falls next ▫ stance time—time during which a foot is in contact with the mat ▫ double support time—time during which both feet are in contact with the mat Statistical analyses of all values were conducted initially with InStat software (version 4. The osteopathic physician (A. The patient’s comorbid conditions at presentation included rheumatoid arthritis and benign prostatic hyperplasia.4 mg daily) and dutasteride (0. and the averages of these values were calculated for pretreatment and posttreatment in both trials. double support time. all of these physicians diagnosed the patient as having a compensated Trendelenburg gait. and alprazolam (0. San Jose.) initiated OMT in 1999 to manage somatic dysfunctions detected throughout the patient’s body.1. He had been diagnosed as having multiple sclerosis in 1991 based on findings from a magnetic resonance imaging (MRI) scan.G.) Videotaped recording of the patient during ambulation was also performed. as needed) for anxiety. in October 2006—during which his gait was analyzed as he walked across the GaitMat II mat. celecoxib (200 mg daily) and hydroxychloroquine sulfate (200 mg daily) for rheumatoid arthritis. Gait Analysis Before and After OMT In the present study. For the present case. stride length. These systems. tamsulosin hydrochloride (0. including interferon beta1a and glatiramer acetate.0. GraphPad Software Inc. as well as the effects of somatic dysfunction and OMT on gait. In each appointment. GaitMat II can be used to assess normal and abnormal gait patterns. We analyzed the following four parameters: ▫ step length—distance along the mat from the “first switch closure” of one footprint to the first switch closure of the next footprint on the contralateral side.5 mg three times daily. during which gait analysis and videotaping of the patient were conducted.CASE REPORT measurements of numerous spatial and temporal gait parameters as a patient walks across a mat.0. Systat Software Inc. that has electronic sensors connected to a computer.16 Therefore. The patient sought care from the osteopathic physician when he experienced marked deterioration in ambulation in March 1999 resulting in the need for a walker and motorized wheelchair. Diagnosis of Somatic Dysfunction Video analysis of the patient demonstrated an antalgic gait with left lateral trunk lean and hip hiking to compensate for decreased clearance of the right leg in the swing phase of the gait cycle. typically the distance from the heel of one foot to the heel of the opposite foot ▫ stride length—distance along the mat from the first switch closure of one footprint to the first switch closure of the next footprint on the ipsilateral side.C.) in 1999 with a chief complaint of back and hip pain.C. the patient had two appointments (ie.G.) and one osteopathic family physician who was board certified in neuromusculoskeletal medicine and osteopathic manipulative medicine. which can aid physicians in diagnosing gait pathologic conditions. Values derived from the GaitMat II analysis for step length. 12 feet in length. This pretreatment video was shown separately to three physicians—two physiatrists (including D. La Jolla.

PϽ. Results showed statistically significant decreases after OMT for both the left and right sides in stance time (left. 0. P=.CASE REPORT Trial 1 Pretreatment Posttreatment (18) (8) Trial 2 (18) (7) Left Right Direction of Motion Figure 1. Figure 1 shows the GaitMat II tracing of the patient’s steps from both trials before and after OMT. Consistent with a compensated Trendelenburg gait. right. +216%. The changes in mean step length. who ordered a new MRI in 2006. These results are consistent with the observed increase in velocity and demonstrate that the OMT sessions resulted in improvements in ambulation. stride length.04] m. The sacrum and innominate bones are in these positions when the left leg is moved forward during ambulation—providing an explanation of why the patient’s left stride was longer at presentation. left lateral trunk lean and hip hiking were noticeably decreased. 0. JAOA • Vol 110 • No 2 • February 2010 • 83 . These results suggest that analysis of step length variation may serve as a diagnostic tool for Trendelenburg gait. with the right step length 41% shorter than the left step length (left. and the posterior rotation of the left innominate was counteracted by manipulating the iliopsoas and rectus femoris muscles to rotate the innominate anteriorly during an isometric contraction.001 for each).01). The Table provides numerical values for two additional parameters—stance time and double support time. right. -33%.05). +85%. Gilliss et al • Case Report This difference vanished after treatment (left. Both the neurologist and a radiologist reviewed the results from this MRI and confirmed the diagnosis of multiple sclerosis. the sacral torsion was addressed by manipulating the left gluteus maximus muscle in an isometric contraction to pull the left sacral base posteriorly.05] m. the patient appeared to benefit from OMT in terms of managing his compensated Trendelenburg gait. Posttreatment analyses using the GaitMat II system provided quantitative evidence that supported the video-based conclusions. PϽ.06] m. An increase of 193% was observed in the patient’s velocity after OMT. analyses revealed significant increases in both left and right step lengths (left. Briefly. The diagnoses for this patient included right-on-right sacral torsion and left posterior innominate somatic dysfunctions. Step patterns of the patient in the present case—a 65-yearold man with compensated Trendelenburg gait—as traced by the GaitMat II (EQ Inc. and velocity after OMT in both trials are provided in the Table and Figure 2. PϽ. This analysis revealed a 58% decrease after treatment in the number of steps taken across the mat. indicating that the OMT was effective. Chalfont. Comment The normal gait of the patient in the present case had been altered primarily through dysfunctions in the sacroiliac joint. as well as an evaluation method for gait improvement after OMT.691).001). right.03] m. The number of steps is shown within parentheses next to each tracing.16 [0. with a pretreatment value of 0. right. -48%. The patient’s gait improvement was such that his neurologist questioned the original 1991 diagnosis of multiple sclerosis and referred the patient to a multiple sclerosis specialist. PϽ. PϽ. -44%. Thus. 0. Pennsylvania) gait analysis system before and after osteopathic manipulative treatment in trial 1 and—1 month later—in trial 2. despite having multiple sclerosis. +136%. with a dramatic decrease in the compensated gluteus medius pattern.81 m per second (PϽ. Specifically. right. +128%. with a mean of 18 steps in the pretreatment analysis and 7. a statistically significant difference was observed between the mean (SD) right and left step lengths before treatment (Figure 3). Results Analysis of the posttreatment video showed substantial improvement in the patient’s gait. 0. This analysis revealed a 58% decrease in the number of steps after treatment.50 [0.27 [0.51 [0.01). right. After OMT. indicative of an improvement in the patient’s compensated Trendelenburg gait. -24%.5 steps in the posttreatment analysis (PϽ.21 m per second and a posttreatment value of 0.001) and double support time (left.001 for each) and left and right stride lengths (left. Follow Up The patient has not needed a walker or wheelchair or used any multiple sclerosis–related medication since 2001.

18) 1.51 (0.50 (0.28 -32. the left sacroiliac joint could not lock into position.06) 0.18 -44.00 (0.33 <.45 (0.21 -47.05) 1.41) (0.80 (0. Conclusion For the patient in the present case. The right-on-right sacral torsion occurred in this patient with the left stride. Clin Rehabil.06) 0.05) 1.63 <.27 (0.88 (0.44 (0.29 1. References 1.07) 0.53 192.05) 0.03) 0. Further research is being carried out (by A.23 (0. Velocity.73 <.02) 0.21) 0. an increase in velocity and decreases in stance time and double support time were measured.01 0.03) 0.35 215. With the left sacral base stuck forward in a rightward rotation about a right oblique axis.G.03 (0.81 <.30 <.16) 18 18 0.001 0.23 85.001 -0. m Left Right Stance Time. m/s ▫ Both trials.50 -58.08) 0.29 (0.03) 0.04) 0.02) 1.40 -0. The patient compensated for this restricted motion by laterally flexing his trunk to the left. through the acetabulum of the innominate.16 (0.21 (0.5 0. improved motion of the pelvis was observed.03) 01.25 (0.22 (0.11) 1.31) (0.07 (0.25 (0. Furthermore.18(2):222-227. it was unable to allow the left sacroiliac joint to close so that the patient’s weight could be balanced effectively on the left leg while the right leg was swung forward. average Ⅲ Posttreatment.43 (0. No.07) 0. as well as to investigate the effects of OMT in alleviating these conditions.43 (0.43 (0.39 (0.04) 0.01 * All values in mean (SD) except for steps and velocity.80 ▫ Trial 2 7 0. 2004.) to clarify the relationship between somatic dysfunctions and gait deviations.C.89 (0.19 <.22 (0.04) 0.17 (0. allowing the patient to increase his speed of walking. energy expenditure during gait was reduced after treatment.87 (0. and the right sacral base could not move forward in a leftward rotation about a left axis—as is required for efficient forward movement of the right leg. s Left Right Steps.23 (0. therefore.29 Stride Length.84 (0.15 1.06) 0.001 <. the right leg could be swung forward without striking the ground and without the patient falling.53 (0.15 (0.28 0.06 (0. Pomeroy VM.47 (0.63 <. Bland M.06) 1. Consistent with this observation. it was not able to return to a neutral position.11) 0.CASE REPORT Table Gait Parameters of Patient With Compensated Trendelenburg Gait Before and After Osteopathic Manipulative Treatment Step Length.98 (0.06) 0.001 -0.04) 0.04) 0.44 (0.05) 0.81 0.09) 0.23 (0.001 0.07) 0.05) 0.06) 1.01 (0.26 0.79 -23.02 (0.04) 0. Giakas G.05) 0.18) 0.51 (0. Similarly.07) 0. After OMT.05) 0.37) 1. The observed decrease in right-left variation and the observed increases in step and stride lengths provided quantitative measures of the beneficial results of OMT.44 (0. Thus.02) 8 0. Gilliss et al • Case Report . OMT resulted in improved gait parameters that could be measured with the use of the GaitMat II system.04) 0. a problem with the right stride resulted.50 (0.57 128. As a result.05) 0.001 -0.05) 0. m Left Right Ⅲ Pretreatment.40 (0. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II.03) 0.06) 0. Because of this inability.09 <.45 (0.03) 0.82 (0. Chambers SH.67 <.01) 0. Mean (SD)* ▫ Trial 1 18 0.001 0.36 (0.15 (0.81 ▫ Both trials.001 -10. including a more normal gait pattern with less evidence of 84 • JAOA • Vol 110 • No 2 • February 2010 lateral trunk lean and hip hiking. average Ⅲ Difference Between Averages ▫ Units ▫ Percent ▫ P value 7.59 135. Mean (SD)* ▫ Trial 1 ▫ Trial 2 0.22 (0.47 (0. s Left Right Double Support Time. the left innominate in this patient was restricted in anterior rotation and. This flexing balanced the weight of the body on top of the femoral head.

Kappler R.0 Figure 2B 1.4 0.8 0. Philadelphia. Heinking K.35(3):543-558. m 0. with the right step length 41% shorter than the left step length (PϽ. In: Whittle MW. Chalfont. Gait Analysis: An Introduction. Normal gait. a statistically significant difference was observed between the mean right and mean left step lengths before osteopathic manipulative treatment. 2002:42-86. Human walking. Consistent with a compensated Trendelenburg gait. Whittle M. eds. Eberhart HD. The pretreatment right stride length was slightly longer than the pretreatment left stride length. Frontera WR. Inman VT.0 Left Pretreatment Posttreatment 0. Saunders JB. After osteopathic manipulative treatment.0 Figure 2C 0.6 Velocity. 5. Step length. Gilliss et al • Case Report 3rd ed. 4th ed.4 0.6 0. An increase of 193% was observed in the patient’s velocity (C) after osteopathic manipulative treatment (PϽ.4 0. In: Ward RC.2 0. Figure 3.0 1. The bars indicate the mean for each parameter. 1953. 2. analyses found significant increases in the left and right step lengths (PϽ.8 Stride Lenght.0 Right Pretreatment Posttreatment Figure 2. 2005:156-167.01). 4. Physical Medicine and Rehabilitation: Principles and Practice. m Step Lenght. Gans BM. 3. Pennsylvania) gait analysis system. Kadyan V. Foundations for JAOA • Vol 110 • No 2 • February 2010 • 85 .001 for both) (B). Bockenek WL.CASE REPORT Figure 2A 1. Bowyer B.0 Left Right 0.2 0. PA: Lippincott Williams & Wilkins. Walsh NE. m/s 0. Chalfont. Pennsylvania) gait analysis system. In: DeLisa JA.001 for both) (A) and left and right stride lengths (PϽ. PA: Butterworth-Heinemann. calculated from the mean for the two trials. and the error bars denote the standard error of the mean. The major determinants in normal and pathological gait.2 0. Pease W. ed.05).6 0. The step length and stride length of the patient in the present case—a 65-year-old man with compensated Trendelenburg gait—as revealed by the GaitMat II (EQ Inc. and velocity of the patient in the present case—a 65-year-old man with compensated Trendelenburg gait—as revealed by the GaitMat II (EQ Inc. Pelvis and sacrum.8 0. stride length. The difference was not statistically significant posttreatment. Philadelphia. J Bone Joint Surg Am.

Jacob HA. Philadelphia. its relationship with cognition [published online ahead of print February 15. Schiowitz S. Newman AB. Munneke M. Brach J. Accuracy. 1965:178-199. 14. DiGiovanna JA. Kissling RO. 7. Eggermont L. Freedman W. An Osteopathic Approach to Diagnosis and Treatment. 6. PA: Lippincott Williams & Wilkins. eds. Mov Disord. http://biomed. researchers. Curr Opin Neurol. CA: Academy of Applied Osteopathy.gerontologyjournals. and validity of a spatiotemporal gait analysis system [published online ahead of print August 24. Studenski S. The role of executive function and attention in gait [review]. Carmel. 2009. 1995. MO: Mosby.” 86 • JAOA • Vol 110 • No 2 • February 2010 Gilliss et al • Case Report . Neurosci Biobehav Rev. JAOA—The Journal of the American Osteopathic Association invites osteopathic physicians.org with the subject heading “JAOA Call for Case Reports. Dowling DJ. J Gerontol A Biol Sci Med Sci. Accessed December 10. Editor’s Note: Video clips of the patient described in the present case walking before and after osteopathic manipulative treatment have been posted online to the JAOA‘s Web site at http://www. Brach J. Aizenstein H. The mobility of sacroiliac joint in healthy subjects. 1986:243. St Louis. 2008. Dutterer L. Apley G. Accessed December 10. and others in the healthcare professions to submit case reports relevant to osteopathic medicine. Submissions should be e-mailed to jaoa@osteopathic. Philadelphia.org/cgi/content/full/110/2/81.23(3):329-342. Kissling RO. Yogev-Seligmann G. 1995:143-158. Hillstrom H. Swaab D. 2005]. Schiowitz S. Dowling DJ. Craik RL. Barker S. 9. JAOA Call for Case Reports To advance the scholarly evolution of osteopathic medicine. Structural pelvic function. 1st ed. 15.org/cgi/content/full/63/12/1380. Bloem BR.21(4):461-471.26:52-60. Med Eng Phys. 1965 Year Book of Selected Osteopathic Papers. 18. Clin Biomech (Bristol. 6th ed. In preparing submissions. Kamsma Y. 2005]. DiGiovanna EL. Longenberger A. 10. 11. Apley’s System of Orthopaedics and Fractures. In: DiGiovanna EL.28(5):460-467. Scherder E. 2008. In: DiGiovanna EL. Gait and postural considerations. 16. http://www. 2004:506-513.63(12):1380-1388. Gait in ageing and associated dementias.” which is available online at http://www. 2007. In: Barnes M. Rosano C. Mitchell FL. PA: Lippincott Williams & Wilkins. de Greef M.gov/pmc/articles/PMC2535903/?tool=pubmed. London. 12.10(7):352-361. Philadelphia. Schiowitz S. Neuroepidemiology. 2003:762-783. authors should adhere to the JAOA’s “Information for Contributors. Boonstra TA.CASE REPORT Osteopathic Medicine. eds.nlm. Gait disorders and balance disturbances in Parkinson’s disease: clinical update and pathophysiology. Longstreth Jr WT. eds. ed. van der Kooij H.org/misc/ifora. 17. Craik R.54(3):158-164. Herrmann N. The mobility of the sacroiliac joints in healthy volunteers between 20 and 50 years of age.shtml. Dowling DJ. Special article: gait measures indicate underlying focal gray matter atrophy in the brain of older adults. 2008. 2006.ncbi. Spatial and temporal characteristics of foot fall patterns. Muscle energy of the lower extremity. 2004:293-303. Oatis CA. Bull Hosp Jt Dis. et al. Jacob HA. Avon). Newman AB.jaoa. PA: Lippincott Williams & Wilkins. England: ELBS. Vol 2. 8. 1996. Rosano C.31(4):485-497. Hausdorff JM. 13. Gait Analysis: Theory and Application. 2009. van Heuvelen M. reliability.nih. 2007]. Giladi N. 2006. In: Craik RL. An Osteopathic Approach to Diagnosis and Treatment.jaoa. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25. 2nd ed.