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A Trendelenburg gait would most likely be caused by which of the following lumbar conditions.
L3/4 far lateral disc herniation
L3/4 central disc herniation with impingement on the bilateral descending nerve roots
L4/5 far lateral disc herniation
L5/S1 far lateral disc herniation
L5/S1 paracentral disc herniation
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A Trendelenburg gait is caused by gluteus medius weakness. Gluteus medius is innervated by L5. Therefore a L5/S1 far lateral disc herniation could cause this condition.
Gluteus medius originates for the dorsal ilium inferior to iliac crest and inserts to the lateral and superior surfaces of greater trochanter. It is the major abductor of thigh, and also functions to help to rotate the hip medially and laterally. Arterial supply is by the superior gluteal artery. It is mediated by the superior gluteal nerve, which is primarily innervated by L5. L5 also contributes to ankle dorsiflexion (combined with L4), great toe extension, and sensory over lateral calf and dorsal foot.
Suri et al. calculated the likelihood ratios (LRs) for the ability of physical exam individual tests to predict the presence or absence of nerve root impingement. They found a LR of > 5.0 indicates moderate to large changes from pre-test probability of nerve root impingement to post-test probability. They found the likelihood ratio of hip abductor weakness being associated with an L5 radiculopathy was 11.
Illlustation V is a 3D illustration showing the function of gluteus medius. Illustration A shows the L5 dermatome.
Answer 1: An L3/4 far lateral disc herniation would cause an L3 radiculopathy and cause hip flexion weakness.
Answer 2: An L3/4 central disc herniation would caused an L4 radiculopathy, leading to knee extension and ankle dorsiflexion weakness.
Answer 3: An L4/5 far lateral disc derniation would caused an L4 radiculopathy, leading to knee extension and ankle dorsiflexion weakness.
Answer 5: An L5/S1 Paracentral disc herniation would lead to a S1 radiculopathy, and would most likely cause ankle plantar flexion weakness.
Suri P, Rainville J, Katz JN, Jouve C, Hartigan C, Limke J, Pena E, Li L, Swaim B, Hunter DJ
Spine. 2011 Jan;36(1):63-73. PMID: 20543768 (Link to Abstract)
Suri, SPINE 2011
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Physical examination maneuver to identify L5-S1 radiculopathy.