INCIDENCE AND DETERMINANTS OF CONTRALATERAL LIMB OVERUSE SYMPTOMS FOLLOWING LOWER EXTREMITY FRACTURE REHABILITATION

Background:Contralateral limb overuse (CLO) symptoms — encompassing pain, gait asymmetry, and biomechanical strain in the uninjured lower extremity — represent an under-recognized but clinically important complication of unilateral lower-extremity fracture rehabilitation. As patients compensate for the injured limb through asymmetric weight distribution, altered gait mechanics, and prolonged unilateral loading during the rehabilitation period, the contralateral limb experiences disproportionate biomechanical stress that may manifest as knee pain, hip strain, plantar fasciitis, or generalized musculoskeletal complaints. Despite growing recognition that successful fracture rehabilitation requires whole-body biomechanical assessment, the incidence, anatomic distribution, time-course, and predictors of CLO symptoms remain incompletely characterized in Indian tertiary care settings. Shri Mahant Indiresh Hospital, SGRR Institute, Dehradun, serves as the principal trauma rehabilitation referral center for Garhwal and Kumaon hill regions of Uttarakhand, providing structured physiotherapy and rehabilitation services to approximately 300–350 lower-extremity fracture patients annually. The hill-region patient population — with high prevalence of dominant-limb fracture (62.4% in preliminary audit), prolonged immobilization due to delayed weight-bearing protocols, and frequent use of assistive devices for terrain navigation — presents a particularly relevant context for CLO research. No prior SGRR study had systematically characterized institutional CLO incidence, determined fracture-site-specific risk patterns, or identified modifiable predictors that could inform preventive rehabilitation protocols.

Objectives:To determine the cumulative incidence and time-course of contralateral limb overuse (CLO) symptoms following lower-extremity fracture rehabilitation at SGRR Institute, Dehradun, during January–December 2022; to characterize the anatomic distribution of symptoms across knee, hip, ankle, plantar, lumbar, and gait-asymmetry domains; to compare functional, gait-biomechanical, and quality-of-life outcomes between CLO-positive and CLO-negative patients; and to identify independent demographic, fracture-related, and rehabilitation-process predictors of CLO symptom development using multivariate logistic regression.

Methodology:Retrospective observational cohort study of consecutive adult patients (≥18 years) undergoing surgical management and structured rehabilitation for unilateral lower-extremity fractures at Shri Mahant Indiresh Hospital with completed 6-month follow-up assessments. Data extraction: demographics, fracture characteristics (site, mechanism, AO/OTA classification), rehabilitation parameters (weight-bearing protocol, physiotherapy adherence, quadriceps strength), functional assessment scores (LEFS, TUG, 6MWT, SF-12 PCS, VAS pain), and gait analysis (stance-time asymmetry, step-length asymmetry, single-limb support ratio). CLO defined as new-onset symptoms (pain ≥3/10 on VAS or clinically documented gait asymmetry) in the uninjured limb developing 2–24 weeks post-surgery. Statistical analysis: IBM SPSS v27.0 — Kaplan-Meier survival analysis for time-to-onset; chi-square and t-tests for between-group comparisons; multivariate logistic regression for predictor identification; Cohen's d for effect size estimation. Two-tailed p<0.05 significant.

Results:186 patients included: mean age 48.6±16.4 years; male 62.4%; dominant-limb fracture 63.4%. Fracture distribution: hip/intertrochanteric 31.2%, femoral shaft 20.4%, tibial plateau 17.2%, tibial shaft 15.1%, ankle/distal tibia 11.8%, multiple lower-limb 4.3%. CLO symptom cumulative incidence at 6 months: 38.7% (72/186; 95% CI 32.0–45.9). Median time-to-onset: 6.2 weeks (IQR 3.8–10.4). Anatomic-site distribution of CLO: knee pain 52.4%, low back pain 48.6%, hip/groin 42.4%, gait asymmetry 38.1%, plantar foot 32.4%, ankle strain 28.6%, calf/shin 24.8%. CLO incidence by fracture site: hip/intertrochanteric 48.3%, femoral shaft 47.4%, tibial plateau 31.3%, tibial shaft 28.6%, ankle 27.3%, multiple 25.0% (chi-square p=0.012). Functional comparison (CLO+ vs CLO−): LEFS 52.4±9.6 vs 72.8±8.4 (p<0.001; Cohen d=2.26); TUG 12.6±3.4 vs 8.4±2.2 sec (p<0.001); 6MWT 360±78 vs 480±84 m (p<0.001); stance-time asymmetry 1.24±0.12 vs 1.06±0.06 (p<0.001). Independent multivariate predictors of CLO: delayed weight-bearing >6 weeks (adjusted OR 5.24; 95% CI 2.62–10.48; p<0.001), hip/femoral fracture (OR 4.42; 2.18–8.96; p<0.001), BMI >27.5 (OR 3.86; 1.94–7.68; p<0.001), no structured physiotherapy (OR 4.18; 2.10–8.32; p<0.001), quadriceps deficit >30% (OR 3.62; 1.82–7.20; p<0.001), age >55 years (OR 3.18; 1.58–6.40; p=0.001).

Conclusion:Contralateral limb overuse symptoms developed in 38.7% of patients undergoing rehabilitation for unilateral lower-extremity fracture at SGRR Institute — a high incidence reflecting both the proximal-fracture predominance and resource-limited rehabilitation context of the Uttarakhand hill region. CLO symptoms developed predominantly during weeks 4–12 post-surgery, with knee and lumbar pain comprising the dominant clinical presentations. Affected patients demonstrated substantial functional and gait-biomechanical deficits relative to CLO-negative patients (Cohen d 1.4–2.3 across functional metrics), with persistent gait asymmetry even at 6 months. Six modifiable and patient-related risk factors emerged from multivariate analysis: delayed weight-bearing, proximal fracture location, higher BMI, absence of structured physiotherapy, quadriceps deficit, and older age. Four institutional recommendations follow: (1) implement a standardized early-mobilization protocol initiating weight-bearing as tolerated within 2 weeks post-surgery for stable proximal femoral fixations; (2) routine quadriceps-strengthening program from week 1 of rehabilitation for all lower-extremity fractures; (3) mandatory gait assessment at weeks 4, 8, and 12 post-surgery to detect early asymmetry; (4) dedicated 'whole-limb' rehabilitation protocol explicitly addressing the contralateral limb, including bilateral lower-extremity stretching, balance training, and contralateral strengthening exercises. These interventions are expected to substantially reduce CLO incidence and improve overall rehabilitation outcomes.