Postural Lower Limb Research Articles

Static postural differences between neutral and flat feet in children with and without symptoms

BackgroundFlatfoot is a common variant of foot posture. Whilst usually benign, in some children flatfoot is accompanied by pain and functional complaints. Comparisons between the posture of asymptomatic and symptomatic flat feet are few. If a difference does exist, it may help understand symptoms and guide management. MethodsThis paper investigated differences in lower limb posture between neutral and flat feet with and without symptoms during standing using the multi-segment Oxford Foot Model. 97 children between five and 18years old were assessed by a physiotherapist; each foot was classified into one of four categories: asymptomatic neutral (n=88), asymptomatic mild flatfoot (n=47), asymptomatic flatfoot (n=29), or symptomatic flatfoot (n=30). For each child, Oxford Foot Model markers were applied, and mean values of 11-Euler angles at the foot, ankle, and knee joints during standing were calculated. Analysis of variance and post-hoc tests were used to identify differences between groups. FindingsHindfoot eversion was significantly increased (P<0.001) in children with asymptomatic and, to a greater extent, symptomatic flatfoot. The forefoot was significantly more abducted (P<0.001) in the symptomatic than asymptomatic groups, and in the flat than neutral group. The forefoot was more supinated relative to the hindfoot in the flatfoot groups (P=0.023), although post-hoc analysis did not identify specific group differences. InterpretationHindfoot eversion and forefoot abduction were much greater in the symptomatic population. The differences in foot alignment may relate to the presence of symptoms.

Mitigating clinician and community concerns about children's flatfeet, intoed gait, or knock‐knees

Background Foot and lower limb postures are a common parental concern, and present frequently to a range of clinicians. Referral of children with flatfeet, intoed gait, or knockknees that is within normal developmental limits has been reported as approximating 40%. This represents a substantial and unnecessary cost to any health care system. The dilemma for caring clinicians is that each of these common presentations can be frankly pathological, so erring on the side of caution is understandable.

Elite and amateur orienteers' running biomechanics on three surfaces at three speeds.

Orienteering athletes must adapt to running on various surfaces, with biomechanics likely contributing to performance. Here, our aims were to identify the effect of athletic status and of surface on the running biomechanics of orienteers. Seven elite and seven amateur male orienteers ran 20 m on road, path, and forest surfaces at maximal, 3.8 m·s, and 85% of maximal speeds. A three-dimensional motion capturing system monitored temporal gait and lower extremity kinematic parameters. Data were analyzed using mixed effects models that considered surface (road-path-forest), group (elite-amateur), and surface-group interaction effects. Forest running at maximal speed was slower and involved longer step and cycle times, greater knee extension at foot strike, smaller peak hip flexion and dorsiflexion during stance, and increased ranges of vertical pelvis motion compared with those observed on the road. Elites specifically exhibited greater hip extension at foot strike, larger dorsiflexion at toe-off, and lower pelvis at foot strike and toe-off, whereas amateurs displayed longer stance, greater plantarflexion at foot strike, and greater knee with lesser ankle motion. At the slowest speed, subjects exhibited greater knee flexion at foot strike, greater dorsiflexion at toe-off, shorter strides, smaller peak dorsiflexion during stance, and greater hip, knee, and vertical pelvis motions on forest than on road surfaces. Elites specifically demonstrated shorter stance, step, and cycle times whereas amateurs did not. Orienteering athletes adjusted their running biomechanics when off-road, with distinct adaptations observed in elite versus amateur competitors. The vertical pelvis motion was consistently greater when running off-road, coherent with reported increases in energy expenditure. However, our athletes did not exhibit more crouched lower limb postures when sprinting in the forest, indicating alternative responses to off-road running to that previously proposed by "Groucho" running.

Biomechanical Aspects of the Lower Limb Positions to the Direct Free Kick at Football

This paper present the aspects regarding the kinematics analysis of the human lower limb, respectively the angular positions and the angular velocities of the body segment, thigh, leg and foot, during of the direct free kick at football. For the analysis were videotaped the direct free kicks of 10 human subjects, children between 10 and 13 years, after which the images were processed using a specialized software. The method of the direct experimental kinematics analysis it allowed the determination of the amplitudes and the angular speeds segmentation advisable for to obtain accurate kicks in the direct free kicks with the ball. Regarding the performance, the objective pursued was that the ball must to have a trajectory on the space of the gate and also exceed the human wall which it is in front of the gate.

The effect of different positions on lower limbs skin perfusion pressure

We have encountered situations of patients with critical limb ischemia accompanied by pain at rest and necrosis, who hang their legs down from the bed during sleep. This lower limb position is known to be a natural position, which reduces pain in the lower extremity induced by ischemia. However, the effect of this position on blood flow of the lower extremity is poorly understood. We studied whether measurements of skin perfusion pressure (SPP) changes by leg position and the difference between healthy adults and patients with critical limb ischemia. The subjects of this study were 10 healthy adults and 11 patients with critical limb ischemia. Patients with critical limb ischemia, including both dorsum of foot and plantar of foot, having SPP of lower limbs of less than 40 mmHg (supine position) were the object of this study. SPP was measured on four positions (supine position, lower limbs elevation position, sitting position, and reclining bed elevation of 20° position). In sitting position, both the number of healthy adults and critical patients show significant increases in SPP compared with the other three positions. These results suggest that sitting position is effective to keep good blood stream of lower limbs not only in healthy adults but also in patients with critical limb ischemia. However, an appropriate leg position should not have lower limbs hang downwards for long periods time because edema is caused by the fall in venous return in lower limbs, and the wound healing is prolonged.Our clinical research could be more useful in the future, particularly in developing countries, for surgeons managing wounds in leg and foot and preserving ischemic limbs.

The relationship between proximal and distal lower limb muscle activities with time to stabilization

Abstract Introduction : Identifying factors which cause the high incidence of ACL is of great importance .The anterior shear forces are the primary mechanism of load sustained on the ACL. During exercise, the activity of muscles and position of lower limbs may increase or decrease the anterior shear force. The purpose of this study is to investigate the relationship between the activity level of some lower extremity muscles and anterior shear force during single-leg jump landing . Materials and Methods: Twenty male-students of physical education participated in this study. EMG activity of the muscles of the gluteus medius, tibialis anterior and hamstring were evaluated via Electromyography system and ground reaction force was evaluated via force plate system in jump-landing task. There was used Pearson correlation test. Results: The results indicated no significant correlation between tibialis anterior and gluteus medius muscles activity with shear force, while there was found correlation between lateral hamstring muscle activity and anterior shear force (P< 0.05 ). Conclusion: The findings of this study showed that hamstring muscle activity during single-leg jump landing acts as a supporting muscle of ACL. This increased muscle activity leads to the reduction of the load on the ACL . Keywords: Electromyography, Anterior Shear Force, Anterior Cruciate ligament, Jump-Landing task, Lower Extremity Muscles

THE RELATIONSHIP BETWEEN ACTIVITY LEVEL OF SOME LOWER EXTREMITY MUSCLE AND ANTERIOR SHEAR FORCE DURING SINGLE-LEG JUMP LANDING

چکیده مقدمه: شناسایی فاکتورهایی که باعث شیوع بالای آسیب ACL می‌شود از اهمیت زیادی برخوردار است. نیروهای برشی قدامی مکانیزم اصلی بار وارده به ACL هستند. فعالیت عضلات و پوزیشن اندام تحتانی طی فعالیت می‌تواند باعث افزایش یا کاهش نیروی برشی قدامی شود. هدف از این مطالعه بررسی ارتباط بین سطح فعالیت برخی از عضلات اندام تحتانی با نیروی برشی قدامی در حرکت پرش-فرود تک‌پا بود. مواد و روش‌ها: 20 دانشجوي پسر رشته تربیت بدنی در اين مطالعه شركت كردند. سطح فعالیت الکترومیوگرافی عضلات سرینی میانی، ساقی قدامی و همسترینگ خارجی با استفاده از دستگاه الکترومیوگرافی، و نیروی عکس‌العمل زمین با استفاده از دستگاه صفحه نيرو در حركت پرش- فرود تک پا ارزیابی شد. به منظور تجزیه و تحلیل داده­ها، از آزمون همبستگی پیرسون استفاده شد. یافته‌ها: نتایج آماری نشان داد که بین سطح فعالیت عضله ساقی قدامی و سرینی میانی با نیروی برشی قدامی ارتباط معنی داری وجود ندارد (05/0P>)، اما ارتباط معنی داری بین سطح فعالیت عضله همسترینگ خارجی با نیروی برشی قدامی یافت شد (05/0P<). نتیجه‌گیری: یافته­های این مطالعه نشان داد که فعالیت عضله همسترینگ در حین حرکت پرش- فرود تک‌پا به عنوان عضله حمایت کننده از ACL عمل می‌کند و افزایش فعالیت این عضله می‌تواند منجر به کاهش بار وارده بر ACL شود. کلیدواژه‌ها: الکترومیوگرافی، نیروی برشی قدامی، لیگامنت صلیبی قدامی، حرکت پرش- فرود، عضلات اندام تحتانی

CHANGES IN MEDIO-LATERAL KNEE JOINT REACTIONS OF FLATFOOT PATIENTS DUE TO INSOLE CONDITIONS

The flattened foot arch causes the mechanical overloading transferred to proximal areas (i.e. ankles, knees, or hips) over time. Thus, the flatfoot is recognized as a contributory factor in a wide variety of musculo-skeletal pathologies in lower extremities. Commonly, flatfoot deformities are treated using specially designed insoles that support the arch and correct the posture of lower limbs. However, the biomechanical effects of the insoles are not yet fully understood, so there still are controversies whether such insoles really have clinical significance [Chen, 2010]. In this study, in order to verify the effects of insoles and determine the best shape of the insoles, we examined how the medio-lateral knee joint reaction force changes due to insole conditions. Since large knee joint reaction force is one of major causes of knee osteoarthritis or knee pain [Radin, 1991], our study will be beneficial in prescribing insoles to prevent knee pathologies of flatfoot patients.

인솔 설계 변수에 따른 발목 과-회내 환자의 보행 시 좌우 방향 무릎 관절 하중의 변화 - 사례 연구

The ankle over-pronation causes the mechanical overloading transferred to proximal areas (i.e. knees or hips) over time. Thus, the over-pronation is recognized as a contributory factor in a wide variety of musculo-skeletal pathologies in lower extremities. Commonly, over-pronated ankles are treated using specially designed insoles that support medial heels and correct the posture of lower limbs. However, the biomechanical effects of the insoles are not yet fully understood, so there still are controversies whether such insoles really have clinical significance. In this study, in order to verify the effects of insoles and determine the best shape of the insoles, we examined how the medio-lateral knee joint reaction force changes due to insole conditions through a case study about a subject. As a result, it is revealed that the medial heel post, which drastically reduced the peak medio-lateral knee joint reaction force, has significant effects on the gait of the over-pronated patients. However, in case that the arch support is combined together, the positive effect of the medial heel post may rather decrease.

Descriptive Analysis of the Posture and Movement in Psychogenic Non-Epileptic Seizures (P02.168)

Objective: To describe the head, trunk, and limb posture and movement of PNES. Background Video EEG monitoring is the gold standard study for the diagnosis of epileptic seizures (ES) from psychogenic non-epileptic seizures (PNES). It has been observed that PNES have distinct head, body, and limb posture or movement that are different from ES. There is a need to describe the semiology of PNES in order to help physicians to differentiate non-epileptic and epileptic motor seizures. Design/Methods: 148 video EEGs in 55 adult PNES patients were retrospectively reviewed and analyzed by the investigators. A minimum of 1 and a maximum of 3 videos of a typical seizure per patient were analyzed. The head, body and limbs were described in terms of their posture, movement and synchronicity. Results: Seventy percent (70%) of the patients was female and were between 18-45 years of age. Bilateral flexion and adduction was a common upper limb posture. Open hand, claw or thumbs up formation were common hand postures (bilateral/unilateral). Bilateral or unilateral flexion-extension at the shoulder or elbow was the common movement seen. Bilateral extension and adduction at the hips and knees was the most common lower limb posture. Flexion-extension or adduction-abduction at the hip and knee occurring unilaterally or bilaterally were the common lower limb movements. PNES patients were frequently observed to have a supine posture with their eyes close and their head in midline position and moving side to side. Pelvic thrusting, rocking movement or side to side truncal movement was seen commonly in decreasing frequency. Asynchronous, irregular and waxing waning character of limb movement was a regular feature. Conclusions: PNES have distinct head, body and limb postures and movements. This will be useful in the diagnosis of PNES. Disclosure: Dr. Lardizabal has received personal compensation for activities with UCB Pharmaceuticals and Abbott Pharmaceutical as a speaker. Dr. Bahl has nothing to disclose. Dr. Lanigar has nothing to disclose. Dr. Sahota has nothing to disclose.

Biomechanical Study of Patient Positioning

The objective of this study was to use finite element model (FEM) simulations and experimental testing to study the relationship between lower limb positioning for surgeries of the spine and changes in sagittal curves. Four volunteers underwent lower limb flexibility and range of motion testing before being placed prone on a new surgical frame where lateral radiographs of their spines were taken in positions of hip flexion (average 48 degrees) and extension (average 13 degrees). Personalized FEMs were created representing each volunteer's spine, rib cage, pelvis, and lower limbs. Optimization of model behavior was performed by adjustment of lower limb muscle initial strains. The FEMs were exploited to examine the impact of more extreme and intermediate lower limb positions; 30 degrees of hip extension to 90 degrees of flexion at intervals of 20 degrees. With increased hip flexion, lordosis and kyphosis decreased to an average of 52% (35 degrees) and 16% (6 degrees), respectively. Personalization of the 4 FEMs allowed reproduction of the experimental results within 5 degrees and their subsequent exploitation showed the linear changes in lordosis and kyphosis between extreme positions decreasing an average of 84% (59 degrees) and 34% (13 degrees) with increased hip flexion. A strong correlation was found between experimental change in lordosis and individual hamstring flexibilities (R=-0.93) which allowed for the development of a predictive equation for lordosis in terms of hip flexion which factors straight leg raise test results. Knowledge gained through this study can be used to improve intraoperative control of sagittal curves through lower limb positioning.

The relationship between vibratory perception and joint position sense testing at the knee

Background: Proprioception may be defined as a specialised sensory modality that gives information about joint position sense (JPS), kinaesthesia and vibratory perception. Vibratory Perception Threshold (VPT) testing has been suggested as an alternative means for assessing proprioception at the knee, as it is believed to travel through the same type of large afferent nerve fibres as JPS. Methods: This study examines the strength of relationship between vibration sense and JPS at the knee in healthy participants and determines the minimum number of trials required for each method to attain constant stable data. Stability was determined by 3 consecutive cumulative standard deviations varying less than 5%. Twenty healthy adults (11 females, 9 males) were tested for VPT at five lower limb positions and JPS at two angles of knee flexion (20° and 60°) using Active Angle Reproduction (AAR). Results: Results showed no significant correlations between VPT and JPS, suggesting the two modalities measure different facets of proprioception. VPT (at all 5 sites) and AAR 20° required 4 repetitions to attain data stability, whereas AAR 60° required five repetitions. There were significant differences (p<0.005) between the five sites tested for VPT with increasing thresholds at more proximal sites. No significant differences were seen between the two angles tested for JPS. Conclusions: The two testing modalities are not interchangeable when testing proprioception, requiring at least 4 repetitions to attain consistent stable data. These findings have implications for clinicians and researchers, encouraging the use of broader proprioceptive assessments and increased repetitions.

下肢の安定性を高める自動車助手席シート・フロア条件

下肢の安定性を高める自動車助手席シート・フロア条件

The Effect of Hip Position on the Length of Trochanteric Muscles: Potential Implications for Early Postoperative Management of Hip Arthroplasty

We investigated the effect several lower limb positions have on muscles that are detached to perform hip arthroplasty through posterior and lateral approaches. We used string models and computer navigation to measure the length changes in these muscles throughout hip movements in the anatomical planes and while simulating several sitting and lying postures. Piriformis and the obturators were shortened by sitting and lying postures when the femur was externally rotated and abducted; the clinical implication being that such postures have the potential to best protect their repair after a posterior approach. The anterior part of gluteus medius was lengthened with femoral external rotation. This lengthening was prevented, and therefore, theoretically, the gluteus medius repair protected after a lateral approach, by neutral or internal femoral rotation.

Do pelvic stabilization and lower-limb position affect isometric trunk extension strength?

Do pelvic stabilization and lower-limb position affect isometric trunk extension strength?

Physical sensor difference-based method and virtual sensor difference-based method for visual and quantitative estimation of lower limb 3D gait posture using accelerometers and magnetometers

An approach using a physical sensor difference-based algorithm and a virtual sensor difference-based algorithm to visually and quantitatively confirm lower limb posture was proposed. Three accelerometers and two MAG3s (inertial sensor module) were used to measure the accelerations and magnetic field data for the calculation of flexion/extension (FE) and abduction/adduction (AA) angles of hip joint and FE, AA and internal/external rotation (IE) angles of knee joint; then, the trajectories of knee and ankle joints were obtained with the joint angles and segment lengths. There was no integration of acceleration or angular velocity for the joint rotations and positions, which is an improvement on the previous method in recent literature. Compared with the camera motion capture system, the correlation coefficients in five trials were above 0.91 and 0.92 for the hip FE and AA, respectively, and higher than 0.94, 0.93 and 0.93 for the knee joint FE, AA and IE, respectively.

Análise do alinhamento dos membros inferiores em crianças com excesso de peso. DOI: 10.5007/1980-0037.2011v13n2p124

Overweight and obesity have reached epidemic proportions, especially among school- children, and have become a global health problem. Many adaptations in postural organization are observed in overweight and obese children, which have serious consequences. Posture assessment contributes to the understanding of these changes. The aim of this study was to assess changes in lower limb posture of overweight and obese children using a specific method. Twenty-two subjects, 9 girls and 13 boys, aged 5-9 years participated in the study. Posture was assessed by photogrammetry using the SAPo software. The lower limb joint angles and plantar projection of the center of gravity were analyzed. Nonparametric and descriptive statistics were used, in addition to the Kruskal-Wallis and Mann-Whitney tests (p < 0.05) for comparison between genders. Both groups showed anterior pelvic tilt and slight rotation (to the right in girls and to the left in boys), hyperextension, and valgus knees and ankles. The center of gravity presented 26.95% anteriorization. In conclusion, posture assessment in this population was consistent with literature findings and the method used permitted the quantification of data for future comparisons.

Somatotopic embodiment of aesthetic processing of human body postures

Event Abstract Back to Event Somatotopic embodiment of aesthetic processing of human body postures Beatriz Calvo-Merino1, 2*, Helge Gillmeister3, Alexander Jones2, Maria Tziraki2, Patrick Haggard4 and Forster Bettina2 1 Universidad Complutense Madrid, Spain 2 City University London, United Kingdom 3 Sussex University, United Kingdom 4 University College London, United Kingdom Aesthetic processing has often been linked to visual, emotional or executive function. However, recent studies using fMRI and TMS have shown a sensorimotor response linked to aesthetic processing of human movements and body postures (Calvo-Merino et al., 2008, 2010), suggesting a relationship between liking and embodiment. Here we present a somatosensory event-related potential study that aimed to clarify the nature of this embodiment and whether associated somatosensory processing is recruited in a body-part specific or general manner during the observation of body postures. We recorded EEG from participants who performed two different judgement tasks during the observation of pairs of body postures: (a) an aesthetic preference task, (b) a perceptual task in which the same pairs of body postures were judged for changes in luminance. In order to understand if embodiment follows a somatotopic structure, we selected body posture pairs that differed in either upper or lower limb positions. Somatosensory event-related potentials were evoked by tactually stimulating hands and feet using small solenoids while participants performed both aesthetic and perceptual tasks. The results showed differences in early somatosensory responses between the two ways of viewing postures (aesthetic, perceptual). Interestingly, we found differences between the aim of the observation (aesthetic, perceptual) and the strength of the somatotopic mapping of body postures. These results show that sensory processes underlie different ways of viewing body postures and suggest that aesthetic processing of human bodies recruits somatosensory cortices in a somatotopic manner. These findings may explain why liking is related to physical sensations and embodiment of an observed piece of art. Funding: Supported by Ramon y Cajal & City University Fellowship. Keywords: EEG, fMRI, Perception Conference: XI International Conference on Cognitive Neuroscience (ICON XI), Palma, Mallorca, Spain, 25 Sep - 29 Sep, 2011. Presentation Type: Poster Presentation Topic: Poster Sessions: Neurophysiology of Sensation and Perception Citation: Calvo-Merino B, Gillmeister H, Jones A, Tziraki M, Haggard P and Bettina F (2011). Somatotopic embodiment of aesthetic processing of human body postures. Conference Abstract: XI International Conference on Cognitive Neuroscience (ICON XI). doi: 10.3389/conf.fnhum.2011.207.00337 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 23 Nov 2011; Published Online: 28 Nov 2011. * Correspondence: Dr. Beatriz Calvo-Merino, Universidad Complutense Madrid, Madrid, Spain, beatriz.calvo@psi.ucm.es Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Beatriz Calvo-Merino Helge Gillmeister Alexander Jones Maria Tziraki Patrick Haggard Forster Bettina Google Beatriz Calvo-Merino Helge Gillmeister Alexander Jones Maria Tziraki Patrick Haggard Forster Bettina Google Scholar Beatriz Calvo-Merino Helge Gillmeister Alexander Jones Maria Tziraki Patrick Haggard Forster Bettina PubMed Beatriz Calvo-Merino Helge Gillmeister Alexander Jones Maria Tziraki Patrick Haggard Forster Bettina Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

농작업에서 발생하는 하지자세의 근골격계 질환 위험도 평가를 위한 인간공학적 평가도구 개발

Objective: To develop an ergonomic evaluation tool which can be apply to assess the lower-limb postures associated with farming tasks. Background: In general, most of existing ergonomic assessment tools was developed to investigate the work-related musculoskeletal disorders of the upper-limb postures in manufacturing industry. Methods: As the first step of development of the evaluation tool, 13 lower-limb postures that were commonly observed in farming task were investigated by the subjective discomfort ratings, heart rates, and muscle activities. And then, an ergonomic evaluation tool for the lower-limb postures was developed based on results of the first experiment. Lastly, the ergonomic checklist which was developed in the current study was compared with other existing ergonomic assessment tools. Results: Based on the results of comparisons between a newly developed assessment tool and other existing assessment tools, it was found that a newly developed tool can perceive more sensitively for the various lower-limb postures than other assessment tools. Conclusions: Lower-limb posture assessment tool which can evaluate and assess risks of lower-limb WMSDs which were prevalent in farming tasks more easily and accurately was developed in this study. The lower-limb assessment tool can also be utilized to prevent WMSDs related with lower-limbs as well as improve working environments.

Sagittal plane deformity: an overview of interpretation and management.

The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.