1. health and fitness
2. therapy
3. physical therapy

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
P
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: [email protected]
Submitted August 22, 2008; final revision received April 13, 2009; accepted
April 22, 2009.
Gilliss et al • Case Report
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
JAOA • Vol 110 • No 2 • February 2010 • 81
CASE REPORT
measurements of numerous spatial and temporal gait parameters as a patient walks across a mat, 12 feet in length, that has
electronic sensors connected to a computer. These systems,
which can aid physicians in diagnosing gait pathologic conditions,13 are increasingly used in the clinical setting.1,14-15
Although the GaitMat II system measures only foot contact patterns recorded on the mat, these patterns arise from
the collective motions of the individual musculoskeletal components that contribute to bipedal locomotion.16 Therefore,
GaitMat II can be used to assess normal and abnormal gait
patterns, as well as the effects of somatic dysfunction and
OMT on gait. 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.C.G.) in 1999 with a chief complaint of back and
hip pain. He had been diagnosed as having multiple sclerosis
in 1991 based on findings from a magnetic resonance imaging
(MRI) scan. From 1991 to 1999, he was treated with standard
medications for multiple sclerosis, including interferon beta1a and glatiramer acetate. 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.
The patient’s comorbid conditions at presentation included
rheumatoid arthritis and benign prostatic hyperplasia. The
patient’s surgical history was unremarkable.
The osteopathic physician (A.C.G.) initiated OMT in 1999
to manage somatic dysfunctions detected throughout the
patient’s body. This treatment has continued to the present day.
For the present case, we focus on two OMT sessions conducted in September and October 2006, during which gait
analysis and videotaping of the patient were conducted.
Medications used by the patient at the time of the present
study included vitamin B12 injections (1000 ␮g, intramuscular,
once weekly); tamsulosin hydrochloride (0.4 mg daily) and
dutasteride (0.5 mg daily) for benign prostatic hyperplasia;
celecoxib (200 mg daily) and hydroxychloroquine sulfate
(200 mg daily) for rheumatoid arthritis; and alprazolam (0.5 mg
three times daily, as needed) for anxiety.
Gait Analysis Before and After OMT
In the present study, the patient had two appointments
(ie, trials)—one in September 2006 and the other 1 month later,
in October 2006—during which his gait was analyzed as he
walked across the GaitMat II mat.13 (Weekly OMT sessions
occurred between these two appointments as part of the
patient’s regular treatment.) Videotaped recording of the
patient during ambulation was also performed. In each
appointment, the GaitMat II analysis and video recording
82 • JAOA • Vol 110 • No 2 • February 2010
occurred once before and once after OMT was administered
by the osteopathic physician.
Values derived from the GaitMat II analysis for step
length, stride length, stance time, double support time, number
of steps, and velocity were recorded for the left and right sides,
and the averages of these values were calculated for pretreatment and posttreatment in both trials. 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, 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, 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 4.0; GraphPad Software Inc,
La Jolla, California) and were repeated with SigmaStat (version 4.0; Systat Software Inc, San Jose, California) and Excel
(Office Professional 2007; Microsoft Corp, Redmond, Washington) software.
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. This pretreatment video was shown separately to three physicians—two physiatrists (including D.J.)
and one osteopathic family physician who was board certified in neuromusculoskeletal medicine and osteopathic
manipulative medicine. Based on this video, all of these
physicians diagnosed the patient as having a compensated
Trendelenburg gait.
Biomechanical examination of the patient during the OMT
sessions revealed somatic dysfunction within the sacroiliac
joints, in addition to other somatic dysfunctions throughout the
body. The sacroiliac diagnoses in both trials were right-onright sacral torsion and posterior rotation of the left innominate.
OMT Application
Osteopathic manipulative treatment was administered to the
patient in each of the two trials. For the right-on-right sacral torsion and the posterior rotation of the left innominate, the
patient was treated with standard OMT muscle energy techniques.16-18
Gilliss et al • Case Report
CASE REPORT
Trial 1
Trial 2
Pretreatment
(18)
(18)
Posttreatment
(8)
(7)
Left
Right
Direction of Motion
Figure 1. 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, Chalfont, Pennsylvania) gait analysis system before
and after osteopathic manipulative treatment in trial 1 and—1 month
later—in trial 2. The number of steps is shown within parentheses
next to each tracing. This analysis revealed a 58% decrease in the
number of steps after treatment, indicative of an improvement in
the patient’s compensated Trendelenburg gait.
Briefly, the sacral torsion was addressed by manipulating
the left gluteus maximus muscle in an isometric contraction
to pull the left sacral base posteriorly, 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.
This difference vanished after treatment (left, 0.50 [0.05] m;
right, 0.51 [0.03] m; P=.691). These results suggest that analysis
of step length variation may serve as a diagnostic tool for
Trendelenburg gait, as well as an evaluation method for gait
improvement after OMT.
The Table provides numerical values for two additional
parameters—stance time and double support time. Results
showed statistically significant decreases after OMT for both
the left and right sides in stance time (left, -33%; right, -24%;
P⬍.001) and double support time (left, -44%; right, -48%;
P⬍.001). These results are consistent with the observed increase
in velocity and demonstrate that the OMT sessions resulted in
improvements in ambulation.
Results
Analysis of the posttreatment video showed substantial
improvement in the patient’s gait, with a dramatic decrease in
the compensated gluteus medius pattern. Specifically, left lateral trunk lean and hip hiking were noticeably decreased,
indicating that the OMT was effective.
Posttreatment analyses using the GaitMat II system provided quantitative evidence that supported the video-based
conclusions. Figure 1 shows the GaitMat II tracing of the
patient’s steps from both trials before and after OMT. This analysis revealed a 58% decrease after treatment in the number of
steps taken across the mat, with a mean of 18 steps in the
pretreatment analysis and 7.5 steps in the posttreatment analysis (P⬍.01).
The changes in mean step length, stride length, and
velocity after OMT in both trials are provided in the Table
and Figure 2. After OMT, analyses revealed significant increases
in both left and right step lengths (left, +85%; right, +216%;
P⬍.001 for each) and left and right stride lengths (left, +136%;
right, +128%; P⬍.001 for each). An increase of 193% was
observed in the patient’s velocity after OMT, with a pretreatment value of 0.21 m per second and a posttreatment value of
0.81 m per second (P⬍.01).
Consistent with a compensated Trendelenburg gait, a
statistically significant difference was observed between the
mean (SD) right and left step lengths before treatment
(Figure 3), with the right step length 41% shorter than the left
step length (left, 0.27 [0.04] m; right, 0.16 [0.06] m; P⬍.05).
Gilliss et al • Case Report
Follow Up
The patient has not needed a walker or wheelchair or used any
multiple sclerosis–related medication since 2001. 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, who ordered a new
MRI in 2006. Both the neurologist and a radiologist reviewed
the results from this MRI and confirmed the diagnosis of multiple sclerosis. Thus, despite having multiple sclerosis, the
patient appeared to benefit from OMT in terms of managing
his compensated Trendelenburg gait.
Comment
The normal gait of the patient in the present case had been
altered primarily through dysfunctions in the sacroiliac joint.
The diagnoses for this patient included right-on-right sacral torsion and left posterior innominate somatic dysfunctions. 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.
JAOA • Vol 110 • No 2 • February 2010 • 83
CASE REPORT
Table
Gait Parameters of Patient With Compensated Trendelenburg Gait Before and After Osteopathic Manipulative Treatment
Step Length, m
Left
Right
Stride Length, m
Left
Right
Stance Time, s
Left
Right
Double Support Time, s
Left
Right
0.29
(0.04)
0.15
(0.05)
0.44
(0.06)
0.45
(0.07)
1.29
1.25
(0.41) (0.18)
0.43
(0.03)
0.25
(0.05)
0.17
(0.06)
0.43
(0.07)
0.44
(0.07)
1.15
1.06
(0.31) (0.11)
0.27
(0.04)
0.16
(0.06)
0.44
(0.06)
0.45
(0.06)
1.22
(0.37)
0.47
(0.04)
0.51
(0.04)
0.98
(0.02)
1.00
(0.06)
0.53
(0.05)
0.50
(0.03)
1.07
(0.05)
0.50
(0.05)
0.51
(0.03)
0.23
85.19
<.001
0.35
215.63
<.001
Steps, No.
Velocity, m/s
0.47
(0.21)
18
0.26
0.36
(0.02)
0.39
(0.04)
18
0.29
1.15
(0.18)
0.40
(0.05)
0.43
(0.16)
18
0.28
0.84
(0.08)
0.87
(0.07)
0.23
(0.04)
0.23
(0.01)
8
0.80
1.03
(0.03)
0.80
(0.03)
0.89
(0.11)
0.21
(0.05)
0.22
(0.03)
7
0.81
1.02
(0.05)
01.01
(0.05)
0.82
(0.06)
0.88
(0.09)
0.22
(0.04)
0.23
(0.02)
7.5
0.81
0.59
135.63
<.001
0.57
128.09
<.001
-0.18
-44.30
<.001
-0.21
-47.67
<.001
-10.50
-58.33
<.01
䡲 Pretreatment,
Mean (SD)*
▫ Trial 1
▫ Trial 2
▫ Both trials,
average
䡲 Posttreatment,
Mean (SD)*
▫ Trial 1
▫ Trial 2
▫ Both trials,
average
䡲 Difference Between
Averages
▫ Units
▫ Percent
▫ P value
-0.40 -0.28
-32.79 -23.81
<.001 <.001
0.53
192.73
<.01
* All values in mean (SD) except for steps and velocity.
The right-on-right sacral torsion occurred in this patient
with the left stride. With the left sacral base stuck forward in
a rightward rotation about a right oblique axis, it was not able
to return to a neutral position. Because of this inability, the
left sacroiliac joint could not lock into position, 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. Thus, a problem with the right stride resulted.
Similarly, the left innominate in this patient was restricted
in anterior rotation and, therefore, 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. The patient compensated for this restricted
motion by laterally flexing his trunk to the left. This flexing balanced the weight of the body on top of the femoral head,
through the acetabulum of the innominate. As a result, the
right leg could be swung forward without striking the ground
and without the patient falling.
After OMT, improved motion of the pelvis was observed,
including a more normal gait pattern with less evidence of
84 • JAOA • Vol 110 • No 2 • February 2010
lateral trunk lean and hip hiking. 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. Furthermore, energy expenditure during gait
was reduced after treatment, allowing the patient to increase
his speed of walking. Consistent with this observation, an
increase in velocity and decreases in stance time and double
support time were measured.
Conclusion
For the patient in the present case, OMT resulted in improved
gait parameters that could be measured with the use of the
GaitMat II system. Further research is being carried out
(by A.C.G.) to clarify the relationship between somatic dysfunctions and gait deviations, as well as to investigate the
effects of OMT in alleviating these conditions.
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Gilliss et al • Case Report
CASE REPORT
Figure 2C
Figure 2B
1.0
1.0
0.8
0.8
0.8
0.6
0.4
0.2
Velocity, m/s
1.0
Stride Lenght, m
Step Lenght, m
Figure 2A
0.6
0.4
0.0
0.0
Left
0.4
0.2
0.2
0.0
0.6
Right
Left
Right
Pretreatment
Posttreatment
Pretreatment
Posttreatment
Figure 2. Step length, stride length, 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, Chalfont, Pennsylvania) gait analysis system. After osteopathic manipulative treatment,
analyses found significant increases in the left and right step lengths (P⬍.001 for both) (A) and left and right stride lengths (P⬍.001
for both) (B). An increase of 193% was observed in the patient’s velocity (C) after osteopathic manipulative treatment (P⬍.01). The bars
indicate the mean for each parameter, and the error bars denote the standard error of the mean, calculated from the mean for the
two trials.
Figure 3. 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, Chalfont, Pennsylvania) gait analysis system.
Consistent with a compensated Trendelenburg gait, a statistically significant difference was observed between
the mean right and mean left step lengths before osteopathic manipulative treatment, with the right step length
41% shorter than the left step length (P⬍.05). The pretreatment right stride length was slightly longer than
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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.jaoa.org/cgi/content/full/110/2/81.
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JAOA Call for Case Reports
To advance the scholarly evolution of osteopathic medicine, JAOA—The Journal of the American
Osteopathic Association invites osteopathic physicians, researchers, and others in the healthcare
professions to submit case reports relevant to osteopathic medicine.
In preparing submissions, authors should adhere to the JAOA’s “Information for Contributors,” which is available online at http://www.jaoa.org/misc/ifora.shtml.
Submissions should be e-mailed to [email protected] with the subject heading “JAOA Call
for Case Reports.”
86 • JAOA • Vol 110 • No 2 • February 2010
Gilliss et al • Case Report