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ASS{SSM{NT

Of GAIT

Walking is the simple act of falling forward and catching oneself. One foot is always in contact with the ground, and within a cycle, there are two periods of single-leg support and two' periods of double-leg support. With running, there is a period of time during which neither foot is in contact with the ground, a period called "double float." Winter felt walking gait performs five main functions.1 First, it helps to support of the head, arms, and trunk: by maintaining a semirigid lower limb. Second, it helps to maintain upright posture and balance. Third, it conu'ols the foot to allow it to clear obstacles and enables gentle heel or toe landing through eccentric muscle action. FOurtll, it generates mechanical energy by concentric muscle contraction to initiate, maintain, and, if desired, increase forward velocity. Finally, through eccentric action of the muscles, it provides shock absorption and stability and decreases forward velocity of the body. The locomotion pattern tends to be variable and irregular until about the age of 7 years.2 Several functional tasks are involved in gait, including forward progression, which is executed in a stepping movement in a wide range of rapid and comfortable walking speeds. econd, the body must be balanced alternately on one limb and then the other; this is accompanied by repeated adjustments of limb length. Finally, there is support of the upright body. Gait assessment or analysis takes a great deal of time, practice, and technical skill combined with standardiza'on for the clinician to develop the necessary skills.3-s _ lost gait analysis today is performed with force platforms o measure ground reaction forces, electromyography to measure muscle activity, and high-speed video motion

analysis systems to measure n1ovement. Discussion -these techniques, however, is beyond the scope of book. This chapter gives only a brief overview of a complex task, assessment of normal and pathological gai detailed assessment of gait is left to other authors.6-14Th various terms commonly used to describe gait, tlle normal pattern of gait, the assessment of gait, and commo abnormal gaits are reviewed.

Definitions5-1o
Gait Cycle
The gait cycle is the time interval or sequence of motio occurring between two consecutive initial contacts of the same foot (Figure 14-1). For example, if heel strike i.5 the initial contact, the gait cycle for the right leg is fro one heel strike to the next heel strike on the same f00The gait cycle is a description of what happens in on leg. The same sequence of events is repeated with th other leg, but it is 1800 out of phase.8 Neumann clear!:described the terminology that applies to the gait cycle events1S (Figure 14-2). Table 14-1 demonstrates the periods or phases of the gait cycle, the function of each phase... and what is happening in the opposite limb.8 The gait cy e consists of two phases for each foot: stance phase, will makes up 60% to 65% of the walking cycle, and swing phase, which makes up 35% to 40% of the walking cycle. In addition, tllere are two periods of double support an . one period of single-leg stance during the gait cycle. As the velocity of the cycle increases, tlle cycle length or stride length decreases. For example, in jogging, the gait cycle is 70% of the walking cycle, and in running.

Figure 14-1
Gait cycle, stride length, and step length.

the gait cycle is 60% that of walking.16 In adclition, as the speed of movement increases, the function of the muscles changes somewhat, and their electromyographic activity may increase or decrease. Generally, gait velocity decreases with age.17 Montero-Odasso et al. found the gait velocity 0.8 m/sec) could be used to determine mobility impairment in the elderly.18

Stages (Instants) of Stance Phase


Initial contact (heel strike) Load response (foot flat) Midstance (single-leg stance) Terminal stance (heel off) Preswing (toe off)

The stance phase of gait occurs when the foot is on the oW1d and bearing weight (Figure 14-3). It allows the wer leg to support the weight of the body and, by so oing, acts as a shock absorber while allowing the body -0 advance over the supporting limb.16 Normally, this hase makes up 60% of the gait cycle and consists of five bphases, or instants.

The initial contact instant is the weight-loading or weight acceptance period of the stance leg, which accounts for the first 10% of the gait cycle. During this period, one foot is coming off the floor while the other foo is accepting body weight and absorbing the shock of initial contact. Because both feet are in contact with the floor. iis a period of double support or double-leg stance.

on the painful tissues. If the knee is weak, the patient may extend the knee by using the hand or may hit the heel hard on the ground to whip the knee into extenion. A patient may do this because of weakness of the muscles (e.g., reflex inhibition, poliomyelitis, an internal derangement of the knee, a nerve root lesion [L2, L3, or L4], femoral neuropathy). In the past, this instant was referred to as "heel strike"; however, with some pathological gaits, heel strike may not be the first instant. Instead, the toes, the forefoot, or the entire foot may initially contact the ground. If the dorsiflexor muscles are weak, the foot drops, slaps, or flops down. The weakness may be caused by a peroneal neuropathy or nerve root lesion (L4). A knee flexion contracture or spasticity may cause the same alteration.

such as artluitis, rigid pes planus, fallen metatarsal or 10 gitudinal arches, plantar fasciitis, or Morton's metat gia. Therefore, patll0logy at tile hip, ankle, or knee moc!iYthe gait in tlus phase.

Terminal Stance (Heel Off)


In the final stages, tile trunk is initially aligned over lower limbs and moves toward the stance leg. The vis is initially level and posteriorly rotated and then to the swing leg side, remaining posteriorly rotated. heel is in neutral and slight medial rotation; the knee extended with the tibia laterally rotated. At the plantar flexion occurs as the critical event. This a helps to smooth the pathway of the center of gravit\. forefoot is initially in contact with the floor, and the weight on the foot moves forward with plantar ion so that only the big toe is in contact with the fi At the same time, the forefoot moves from inversio everSiOn.

Load Response (Weight Acceptance or Foot Flat)


Load response is a critical event in that the person subconsciously decides whether the limb is able to bear the weight of the body. The trunk is aligned with the stance leg. The pelvis drops slightly on the swing leg side and medially rotates on the same side. The flexed and laterally rotated hip moves into extension, and the knee flexes 15 to 25. The tibia is medially rotated and begins to move forward over the fixed foot as the body swings over the foot. The ankle is plantar flexed, and the hindfoot is inverted. The foot moves into pronation, because this position unlocks the foot and enables it to adapt to different terrains and postures. The forefoot is pronated, unlocking the subtalar and metatarsal joints to enable them to absorb the shock more effectively, and the plantar aspect is in contact with the floor. Abnormal responses include excessive or no knee motion as a result of weak quadriceps, plantar flexor contractures, or spasticity.9

Preswing (Toe Off)


The preswing phase is the acceleration phase as the pushes the leg forward. The trunk remains erect, the vis remains posteriorly rotated, and the lup is exten and slightly medially rotated. The knee flexes to ~to 35 (critical event), and the ankle is plantar fie Because the center of gravity is anterior to the hip. hip can be accelerated forward in initial swing. If pain is elicited during this instant, it may be callS by a hallux rigidus, turf toe, or any otller patho =involving tile great toe (hallux), especially the me sophalangeal joint of tile hallux. With injury to the j . the patient is unable to push off on tile medial asp the foot; instead, the patient pushes off on the laL aspect of the foot to compensate for the painful me sophalangeal joint or, in some cases, a painful meta arch resulting from increased pressure on the meta heads. If the plantar flexors are weak (e.g., SI-52 ner root pathology), push-off may be absent. During . phase, the foot pronates so tlut there is a rigid base .:better push-off. During walking, a cane can be used to decrease load on the limb. Lyu and associates have shown using a cane in the contralateral upper limb,36 if the tip touches the ground at the same time as the heel reduce the force at heel strike by 34%, by 25% at stance, and about 30% at toe off.

Midstance (Single-Leg Support)


The midstance instant is a period of stationary foot support. Normally, the weight of the foot is evenly distributed over the entire foot. The trunk is aligned over the stance leg, and the pelvis shows a slight drop to the swing leg side. During this stage, there is maximum extension of tile hip (lO to 15) with lateral rotation, and the greatest force is on the hip. Painful hip, knee, or ankle conditions cause this phase to be shortened as the patient hurries through the phase to decrease the pain. If the gluteus medius (L5 nerve root) is weak, Trendelenburg's sign is present. The knee flexes, and the ankle is locked at 5 to 8 of dorsiflexion, rolling forward on the forefoot (rolloff). The foot is in contact with tile floor; the forefoot is pronated, and the hindfoot is inverted. Tlus instant is a critical event for the ankle. If pain is elicited during this period, the phase will be shortened and the heel may lift off early. This pain is commonly caused by conditions

Swing Phase
The swing phase of gait involves the lower limb in open kinetic chain; tile foot is not fixed on the gro and the stresses on tile limb are therefore less and to dissipate. During this phase, alterations occur from spine down through the pelvis, hip, ankle, and foot. TI

Table 14-3 Summary of Joint Motion and Forces during Swing Phase: Acceleration to Midswing and Midswing to Deceleration Acceleration to Midswing Joint Hip Kinematic Motion Slight flexion (0 to 15) moving to 30 flexion and lateral rotation to neutral Kinetic Motion Hip flexors working concentrically to bring limb through; contralateral gluteus medius concentrically contracting to maintain pelvis position Hamstrings concentrically contracting Midswing to Deceleration Kinematic Motion Continued flexion at about 30 to 40 Kinetic Motion Gluteus m:Lumus contracting eccentrically to slow hip flexion

Knee

Ankle and foot

30 to 60 knee flexion and lateral rotation of tibia moving toward neutral 20 dorsiflexion and slight pronation

Dorsiflexors contracting concentrically

Moving to near full extension and slight lateral tibial rotation Ankle in neutral; foot in slight supination

Quadriceps femoris contracting concentrically and hamstrings contracting eccentrically Dorsiflexors contracting isometrically

pelvis and hip provide the most stability in the lower limb during the non-weight-bearing phase. Table 14-3 summarizes the motions occurring in the lower limb during the swing phase. The three instants composing the swing phase of gait are now described in order of occurrence.

(e.g., drop foot), the patient demonstrates a steppage gait (see Figure 14-24). In such a gait, the hip flexes excessively so that the toes can clear the ground.

Terminal Swing (Deceleration)


During the final subphase, the hip continues to flex and meclially rotate, and the knee reaches its maximum extension. At the ankle, dorsiflexion has occurred. The forefoot is supinated, and the hindfoot is everted. The trunk and pelvis maintain the same position as before. The hamstring muscles contract during the terminal phase to slow the swing; if the hamstrings are weak (e.g., SI-S2 nerve root lesion), heel strike may be excessively harsh to lock the knee in extension.

Initial Swing
During the first subphase of acceleration (Figure 14-11), flexion and medial rotation of the hip and flexion of the knee occur. The pelvis medially rotates and clips to the swing leg side. The trunk is aligned with the stance leg. In addition, the ankle continues to plantar flex. The foot is not in contact with the floor. The forefoot continues supinating, and the hindfoot continues everting. The dorsiflexor muscles of the ankle contract to allow the foot to clear the ground, and the knee exhibits its maximum flexion during gait of about 60. If the quadriceps muscles are weak, the trunk muscles thrust the pelvis forward o provide forward momentum to the leg.

Midswing
During the midswing instant, the hip continues to flex and medially rotate, and the knee continues to flex. The ankle is in the anatomical or plantigrade position (90) or the first 25% of the stance phase to permit the foot and midtarsal joints to unlock so that the foot can adapt o uneven terrain when it begins weight bearing. The orefoot is supinated, and the hindfoot is everted. The lvis and trunk are in the same position as during the revious stage. If the ankle dorsiflexor muscles are weak

Although there is a tendency to talk about gait as action around joints, the examiner must not forget that muscles play a significant role in what happens at the joints. Table 14-4 illustrates the actions of some of the muscles used during gaitY Hip. The function of the hip is to extend the leg during the stance phase and flex the leg during the swing phase. The ligaments of the hip help to stabilize it in extension. The hip extensors help to initiate movement, as do the hip flexors; both groups of muscles work phasically. The hip flexors (primarily the iliopsoas muscle) contr'a to slow extension; the hip extensors (primarily the hamstring muscles) contract to slow flexion. In this way work eccentrically. The abductor muscles provide stabiliirr during single-leg support, a critical event for the hip.

Weight Acceptance Reference Limb Opposite Limb

Single Limb Support

Swing Limb Advancement

le
PSw

LR

MSt

TSt

PSw

ISw

MSw

TSw

PSw

ISw/MSw

TSw

IC/LR

MSt

MSt

TSt

PELVIS

5 Fwd Rotation

5 Fwd Rotation

5 Bkwd Rotation

5 Bkwd Rotation

5 Bkwd Rotation

5 Fwd Rotation

HIP

25 Flex

25 Flex

20 Apparent Hyperext

15 Flex

25 Flex

25 Flex

KNEE

15 Flex

40 Flex

60 Flex

25 Flex

ANKLE

@o

100Plantar Flex

5 Dorsiflex

10 Dorsiflex

20 Plantar flex

10 Plantar flex

30 MTP Ext

60 MTP Ext

Figure 14-11
ormal range of motion during gait cycle. IC = initial contact; LR = load response; MSt = midstance; TSt = terminal stance; PSw ~ preswing; ISw = initial swing; MSw = midswing; TSw = terminal swing. (Copyright 1991 LAREI, Rancho Los Amigos Medical Center, Downey, Calif90242; from The Pathokinesiology Service and The Physical Therapy Department, Rancho Los Amigos Medical Center: Observational Gait Analysis. Downey, Calif, Los Amigos Research and Educational Institute, Ine., 1996, p. 30.)

Table 14-4 Muscle Actions during Gait Cycle Phase of Gait Stance Phase Initial contact Loading response Midstance Terminal stance Swing Phase Preswillg Initial swing Midswing Terminal swing Mechanical Goals Active Muscle Groups Examples

Position foot, begin deceleration Accept weight, stabilize pelvis, decelerate mass Stabilize knee, preserve momentum Accelerate mass Prepare for swing Clear foot, vary cadence Clear foot Decelerate shank, decelerate leg, position foot, prepare for contact

Ankle dorsiflexors, hip extensors, knee flexors Knee extensors, hip abductors, ankle plantar flexors Ankle plantar flexors (isometric) Ankle plantar flexors (concentric) Hip flexors Ankle dorsiflexors, hip flexors Ankle dorsiflexors Knee flexors, hip extensors, ankle dorsiflexors, knee extensors

Anterior tibialis, gluteus maxim us, hamstrings Vasti, gluteus medius, gastrocnemius, soleus Gastrocnemius, soleus Gastrocnemius, soleus Iliopsoas, rectus femoris Tibialis anterior, iliopsoas, recms femoris Tibialis anterior Hamstrings, gluteus maximus, tibialis anterior, vasti

If there is loss of movement of the hip, the compensatory mechanisms are increased mobility of the knee on the same side and increased mobility of the contralateral hip. In addition, the lumbar spine shows increased mobility. Knee. yvhen the knee is in flexion during the first three instants of the stance phase of gait, it acts as a shock absorber. Painful knees are not able to do this. One of the critical events of the knee is extension. The functions of the knee during gait are to bear weight, absorb shock, extend the stride length, and allow d1e foot to move through its swing. The quadriceps muscles use only 4% to 5% of their maximum voluntary contraction to extend the knee, but in so doing, they help to control weight acceptance. The hamstring muscles flex the knee and low the leg in the swing phase, working eccentrically. If the knee has a flexion deformity, the hip is flexed and therefore loses its extension power, which is a critical event for the hip. Pathological conditions such as patellofemoral syndrome also cause deviations from normal gait. For exan1ple, patients with patellofemoral syndrome how less knee flexion during the single-leg stance phase, ombined with lateral femoral rotation during the swing hase.39 On heel strike to foot flat, the femur then medially rotates, and if this compensating medial rotation " too great, it causes excessive pronation, which then stresses the medial aspect of the patellofemoral joint. Gastrocnemius and Soleus. The gastrocnemius and soleus muscles are important in gait. They use 85% of their maximum voluntary contraction during normal . alking. These muscles help to restrain the body's for"ard momentun1 during forward movement. They also -ontribute to knee and ankle stability, restrain forward

rotation of the tibia on d1e talus during the stance phase, and minimize the vertical pelvic shift, thereby conserving energy.'w To accomplish these functions during gait, the triceps surae work eccentrically and concentrically. Foot and Ankle. The foot and anlde play major roles in gait in that the various joints allow the foot to accommodate to the ground. The joints of the foot and ankle work interdependendy during normal gait. When the heel contacts the ground, the lower limb becomes a closed kinetic chain, and movements and stresses must be absorbed by the structures of the lower limb. When looking at the ankle, d1e examiner should observe immediate plantar flexion at initial contact. Loss of dus plantar flexion (e.g., tibial nerve neuropathy) results in an inability to transfer weight to the anterior foot, increased ankle dorsiflexion, and increased knee flexion. In addition, the duration of single-leg stance on the affected side decreases, and the step length on the opposite side decreases. Furthermore, quadriceps action at d1e knee increases because of the lack of knee stability caused by the loss of the triceps surae, with the end result being that walking velocity decreases.4o The foot then dorsiflexes through midstance or single-leg stance, with maximum dorsiflexion being reached just before heel off. The examiner should note whed1er d1ere is sufficient plantar flexion during push-off.

The assessment of a patient's gait should be include any assessment of the lower limb. The examiner ID keep in mind that the posture of the head, neck, rho and lumbar spine can affect gait even if no pathology --

evident in the lower limb. The examiner must be able to identifY the action of each body segment and note any deviation from normal during the individual phases of gait. For this reason, it is important to understand the normal parameters of gait and the mechanism of gait as it occurs. With this knowledge, the ways in which the gait is altered under pathological conditions can be better understood. Musculoskeletal pathology tends to modifY gait because of muscle weakness, pain, or altered ROM, so the examiner should watch closely for these factors when observing gait. Many patients can adapt automatically to these changes, provided they have normal sensation and can develop selective controP Patients with upper motor neuron lesions have greater alterations and cannot easily adapt because, in addition to the musculoskeletal problems, they also present with spasticity, control problems, and sensory disturbances.9 It is important that the examiner read the patient's chart and take a history from the patient regarding any disease or injury, past or present, that may be causing gait problems.

The examiner should first perform a general overview of the patient's posture, looking for any asymmetry, and then observe the patient's gait, looking at stride length, step frequency, time of s~g, speed of walking, and duration of the complete walking cycle. This is normally done with the patient in shorts, wearing no shoes or socks. If gait is observed wearing shoes, the same shoes should be used for each testY A steady gait pattern is usually established within three steps; it is initiated by the body's becoming unbalanced so that the patient can lift one foot off the ground to take the first step.42 After this overview is completed, the examiner can look at specific parts of the gait in terms of phases and what happens at each joint during these phases. Because gait constantly changes as one stops and starts, hurries, dawdles, and walks with others, it is important to remember whether the movements the patient is capable of are normal and whether the speeds, phases, strides, and durations of the cycles occur in normal combinations. In addition to observing walking at a normal speed, the patient's slow and fast gait speeds should be examined to see whether these changes affect the gait. The examiner must watch the upper limbs and trunk, as well as the lumbar spine, pelvis, hips, knees, feet, and ankles during these changes. Female patients should be in a bra and briefs, and male patients should be in shorts. The patient should walk barefoot. In this way, the motions of the toes, feet, legs, pelvis, trunk, and upper limbs can properly be observed. The examiner should ask the patient to walk in the usual manner, using any aids necessary (e.g., parallel bars,

crutches, walker, canes). While the patient is walking.. the examiner makes an initial general observation of an: obvious limp or deformity. The examiner should observe the gait from the fron from behind, and from the side, in each instance obsen-ing from proximal to distal and watching the pehand lumbar spine down to the ankle and foot as \ e as from the foot up. For example, in the swing phase (open kinetic chain) movement starts proximally an moves distally. In the stance phase (closed kinetic chain _ movement is reversed, starting in the foot and movin= proximally. The examiner should observe the moycments in the trunk and upper limbs, which normally ar in the opposite direction to those of the lower lim This method provides a sequential, thorough mann of assessment. Rancho Los Amigos Medical Center has developed a useful gait analysis chart (Figure 14-12 By using the chart during observation, the examiner determine deviations and their effect on gait in an easily used and easily retained method of recording. Th dark gray boxes indicate what normally should oc the lighter gray and white boxes indicate minor an major deviations from the normal, respectively. Mi.n deviations imply that the functional task of walking' not affected. Major deviations imply that the mechani of walking are affected adversely.43

Anterior View
When observing from the front as tlle patient walks, examiner should note whether any lateral tilt of the vis occurs, whether there is any sideways swaying of trunk, whether the pelvis rotates on a horizontal plane.. whetller the trunk and upper extremity rotate in opposite direction to the pelvis, and whether reciprocal arm swing is present. Usually, tlle trunk and uppc extremity rotation is approximately 1800 out of phase with the pelvis-that is, as the pelvis and lower lim rotate one way, the trunk and upper limb rotate in opposite direction. This action helps provide a balancing effect and smoothes the forward progression of th body. The examiner may also note movements at th hip (rotation and abduction-adduction), knee (rotati and abduction-adduction), and ankle and foot (amo of toe-out and toe-in, dorsiflexion-plantar flexio . supination-pronation). The examiner should note an. bowing of the femur or the tibia, any medial or late rotation of the hips, femur, or tibia, and the position .the feet as the patient goes through the gait cycle (Figure 14-13). This view is best used to examine the weigh loading period of the gait cycle. The examiner sho also note whether there is any abduction or circumduction of the swing leg, whether there is atrophy of th musculature of the anterior thigh and leg, and wheth the base width is normal.

GAIT
PHYSICAL

ANALYSIS:
THERAPY DEPARTMENT

FUll

BODY

RANCHO LOS AMIGOS MEDICAL CENTER

Reference Limb:

LO RO
C- I Major De>iation
E"
Trunk
Weight Accept Single Limb Support SwingLirnb Advancement

MAJOR

Minor Deviation Lean: BIF Lateral Lean: RlL Rotates: BIF Hikes Tilt PIA Rotation Rotation Rotation Rotation Drop Drop limited Excess

le

LR

MSt

TSt

PROBLEMS:
Weight Acceptance

Pelvis
Lacks Forward Lacks Backward Excess Forward Excess Backward

Ipsilateral Contralateral

Hip

Flexion: Inadequate

Single Limb Support

Extension Past Retract

Rotation: IRIER Adl Abduction: Adl Ab

Knee

Flexion: Limited Excess Inadequate Extension Wobbles Hyperextends Extension Thrust VarusNalgus: VrlVl

Swing Limb Advancement

Excess Contralateral

Flex

Ankle

Forefoot Contact Foot-Flat Contact Foot Slap Excess Plantar Flexion

Excess Dorsiflexion Inversion/Eversion: fvlEv Heel Off No Heel Off Drag Contralateral Vaulting

Excessive DE Weight Bearing

Toes
Inadequate

Up Extensj~n Clawed

Figure 14-12
Gait analysis of the full body. (Copyright 1996 LAREI, Rancho Los Amigos Medical Center, Downey, Cal.if90242; from the Pathokinesiology Service and the Physical Therapy Department, Rancho Los Amigos Medical Center: Observational Gait Analysis. Downey, Cal.if, Los Amigos Research and Educational Institute, Inc., 1996, p. 64.)

Lateral View
From the side, the examiner should observe rotation of the shoulder and thorax during the gait cycle, as well as reciprocal arm swing. Spinal posture (e.g., lordosis), pelvic rotation, and movements in the joints of the lower limbs should be noted. These movements include flexion-extension at the hip, flexion-extension at the knee, and dorsiflexion-plantar flexion at the ankle. From the lateral aspect, the examiner may also observe length, stride length, cadence, and the other time dime sions of gait (see Figure 14-6).33 This view allows 0 vation of the interactions between the walking and the various body parts.

posteriorly, as well as hip, knee, ankle, and subtalar jo movement. Heel rise and base of support (base wi are easier to view posteriorly. Any abnormal abductio adduction movements or lateral displacement of the segments should be noted. This view is best to ex the weight-unloading period of the gait cycle. The ex iner can note whether heel rise is equal for both feet ~ whether the heels turn in or out. The observation h also include lateral movement of the spine and the m lature of the back, buttocks, posterior thigh, and calf

Footwear
Figure 14-13 During stance and gait, dle toes angle our 5 to 18 (Fick angle).

The examiner must remember that there may be some compensation by the lumbar spine for limitation of movement in the hip. The patient should be observed to determine whether there is sufficient knee extension at initial contact, followed almost immediately by slight flexion until the foot makes contact with the floor; whether there is control of the slightly flexed knee during load response and midstance; and whether there is sufficient flexion during preswing and initial swing. Also, any hyperextension of tlle knee during the gait cycle should be noted. Finally, the examiner should note whetller there is coordination of movement among the hip, knee, and ankle; even or uneven gait length; and even or uneven duration of steps. As the patient moves from initial contact to loading response, the foot flexes immediately, and the knee flexes until the foot is flat on the floor. During this period, the hip is also flexed. During midstance, the ankle dorsiflexes as the body pivots in an arc over the stationary foot. At the same time, the hip and knee extend, lengthening the leg. As tlle patient moves from terminal stance to preswing, the ankle plantar flexes to raise the heel, and the hip and knee flex as the weight is transferred to the opposite leg. During tlle initial swing, the ankle is plantar flexed, and the hip and knee are maximally flexed. As the leg progresses to midswing, the ankle dorsiflexes, and the hip and knee begin to extend. As the patient moves from midswing to terminal swing, the ankle remains in the neutral position while the hip and knee continue extending. As the leg moves from terminal swing to initial contact, the knee reaches maximum extension; the ankle remains in neutral, and no furtller hip extension occurs at this stage.

The patient should be asked to walk in normal fi -. wear as well as in bare feet. The examiner should time to observe the patient's footwear and observe wearing down of the heels or socks, the condition of shoe uppers, creases, and so on. The feet should be examined for callus formations, blisters, corns, anbunions. Different shoes can modify a patient's gait anthe amount of energy necessary to perform gait. F example, high-heeled shoes alter movement, especiaL.. at the knee and ankle, which in turn increases the verti 10ading.44

Most gait assessment involves observation. However, rh examiner should take time, especially if he or she notie altered gait, to measure muscle strength (active and resiste movement) and range of movement (active and passi,-e movement) at each joint involved in tlle gait cycle. The parameters of gait (see normal parameters 0"gait) may also be measured to see if tllere are differenc between the left and right gait cycles.4s,46 Leg length discrepancies (see Chapter 11 for leg length measurement) may also affect gait. Children tend to have bette compensation mechanisms for leg length discrepanci than do adults.47 Table 9-7 gives functional causes of leg length differences. Tables 11-10, 12-2, and 13-2 outline mal alignments that may also affect gait.

Locomotion Scores
In addition to the detailed assessment of gait, locomotion scales or grading systems have been developed that include subjective and objective scores, which are combined for a total score. Figure 14-14 is a locomotion scoring scale that was developed for rheumatoid arthritis.' Figure 14-15 shows the modified Gait Abnormality Scale (GARS-M) for elderly people who may be at high risk to falling.49-S1 In addition to including all aspects oflocomotion, it gives an overall estimation of functional disability for patients with rheumatoid arthritis. Wolf and associates reported on the Emory Functional Ambulation Profile and established its reliability and validity.s2,53The profile

Posterior View
When observing the gait cycle fi-om behind, the examiner should notice the same structures that were viewed from the front. Rotation of the shoulders and thorax, reciprocal arm swing, and pelvic list and rotation may be noted

Detailed and Total Locomotion Score in Chronic Arthritis


UPPER EXTREMITIES A. Subjective score (max. 100 points) 19-20. Wash the axillas 21-22. Reach things over shoulder level 23-24. Use of walking support(s) Sum: right _ left_ sO 0 sO 0 120 0 70 0 20 0 20 0 40 0 00 R 19 L 20 Pain (max. 33 points) 33 None at ordinary activity 2S Mild, inconstant, unilaterally, not interfering with normal activity 17 Mild bilateral or moderate unilateral, constant use of analgesics 10 Moderate pain despite large doses of analgesics, affecting activity Severe pain despite large doses of analgesics. affecting activity o Severe bilateral, unable to work and use walking supports, prevents physical activity Pain score reduction -10% Unilateral hand pain -2S% Bilateral hand pain - 2S% Severe pain from both lower extremities or neck Sum:_ ABILITY (max. 67 points) Degree of disability Severe or General (max. 20 points) Mild None Moderate unable . ORs S-6. Manage work, 60 3D 80 OD L 6 household routines, 0 0 0 shopping. child care (min. 3 of 4) 7-8. ADL (home and kitchen chore, personal care, dressing, etc.)
Drive a car or use

o o

00 R 21 L 22 00 R 23 L 24

Both (R/2 + L/2)_

Right Shoulder (max. 35 points) 2S-26. Flexion: 27-28. Extension: 29-30. Abduction: 31-32. Medial rot.: 33-34. Lateral rot.: Elbow (max. 35 points) 3S-36. Flexion (from 90): >90 <4S >20 O' ; >90 <4S >lS >10 ; lOp, 4S-90 ; S p, ; Op ; Sp, 0-20 ; 3p, Op ; lap, 4S-90 ; Sp, ; Op ; Sp, <lS ; Op ; Sp, <10 ; Op 02S 027 029 031 033 o3S 037 039 041

Left 026 028 030 032 034 036 038 040 042

70 0

sO 0

20 0

00 R 7 L8

9-10.

public transportation Special (max. 47 points) 11-12. Feeding (hold knife, cup, open milk pack) 13-14. Carry 3 kg burden lS-18. Use telephone 17-18. Comb hair, brush teeth. shave

sO 0

20 0

00 R 9 L 10

>120 ; lOp, 100-120 ; 7p, 90-100 ; 4p, O' ; Op 0-30 = lOp, 30-60 ; 7p, 60-90' ; 4p, 90 ; Op 39-40. Deformity: none + stable ; Sp, rigid deformity = 2p. laxid = Op 41-42. Varus-valgus: <So = lOp, S-10 ; 7p stressed varus-valgus >lS ; 3p, >2S' ; Op 37-38. Extension defect: Wrist (max. 15 points) 43-44. Deformity (rigid, laxid): none = lSp, mild = lOp, mode'rate ; Sp. severe; Op Hand (max. 15 points) 45-46. Deformity (rigid, laxid): none = 15p, mild; lOp, moderate; severe; Op Sum: right _ left _

100 0 -0 ~O sO 0 sO 0

70 0

40 0 20 0 20 0 20 0

00 R 11 L 12

00 R 13 OL14 00 R lS L 16

Sp,

045

046

Both (R/2 + L/2)_ SUBJ. + OBJ. SCORE: (upper extremities)

00 R 17 o L 18

OBJECTIVESCORE: _

(a)

Figure 14-14
Locomotion scoring scale. (Modified fi-om Larsson SE, Jonsson B: Locomotion score in rheumatoid arthritis, Acta Orthop Scand 60:272,1989. Munksgaard International Publishers, Ltd., Copenhagen, Denmark.)

measures different tasks and surfaces for stroke patients and can differentiate between those suffering from a stroke and normals. The profile does time trials and measures such things as a 5-meter (16.4 feet) walk on bare floor and carpeted floor, an "up and go" task, negotiating an obstacle course, and stair climbing. Other fi.mctional tests include the Get Up and Go Test,54 the Functional Ambulatory Classification Scale,55,56 and the Performance Oriented Balance and Mobility Assessment (POMA)Y

tain an energy-saving gait. The patient tries to use the most energy-saving gait possible.58 Speed of walking can also modify many of the normal parameters of gait.59 Therefore, not only the gait pattern but also the speed of the activity and its effects must be noted. This type of assessment allows the examiner to set appropriate goals and plan a logical approach to treatment.

The examiner must try to determine the primary cause of gait faults and the compensatory factors used to main-

Gait deviations can occur for three reasons. First, they occur because of pathology or injury in the specific . (Table 14-5). Second, they may occur as compensario injury or pathology in other joints on the same or .

Detailed and Total Locomotion Score in Chronic Arthritis-(Cont'd)


WWER EXTREMITIES can use public transportation = 2p, unable = Op 47. Pain (max. 44 points) 44 None at ordinary activity 40 Slight, occasional ache or awareness of pain, not influencing activity 30 Mild bilateral or moderate unilateral, may take analgesics 20 Moderate, affecting ordinary aclivities and work, consistent use of analgesics. 10 Severe pain in spite of optimal medication o Severe, preventing most of activity or patient bedridden Pain score reduction - 25% Moderate or severe pain from more than one ipsilateral joint - 50% Moderate or severe pain from more than one contralateral joint -10% Severe pain from upper extremities or neck

D.

Objective score-physical

signs (max. 100 points) Right Left 059 061 063 065 06i

48-50.

Hip (max. 35 points) 58-59. Flexion: 60-61. Extension defect: 62-63. Abduction/adduclion: 64-65. Rotation: Knee (max. 35 points) 66-67. Flexion:

>90 = lOp, 60--90 = 5p, <60 = Op 0-10 = lOp, 10-30 = 5p, >30 '= Op >10 = lOp, -10-10 = 5p, <-10 = Op >0 = 5p, O = Op >100 = lOp, 80--100 = 8p, 60--80 = 5p 00 = lOp, 0-100 = 8p, 10200 = 5p 20-30 = 2p, >30 = Op <70 = lOp, 7-150 = 8p stressed v/v 15-300 = 5p, >30 = Op none + stable = 5p, rigid = 2p, laxid = Op

058 060 062 064

066

Walk (max. 36 points)


51. Limp:

none = 12p, slight = 8p, moderate = 5p, severe = Op none = 12p, cane for long walks = Bp, cane most of time = 5p one crutch or can't use = 3p, two canes = 2p two crutches or can't walk = Op unlimited = 12p, >400m = 8p, <400m = 5p indoors only = 2p, bed or chair = Op without difficulty = 6P with difficulty or by using banister
3p

68-69. Extension defect: 70-71. Varus-valgus:

068 070 072

069 071 073

0 72-73. Deformity: 0

Ankle (max. 15 points) 74-75. Deformity (rigid, laxid): none = l5p, mild = lOp, moderate = 5p, severe = Op 0 Feet (max. 15 points) 76-77. Deformity (rigid, laxid): None = l5p, mild = lOp, moderate = 5p, severe = Op SUM: right: _ OBJECfIVE SCORE: _ left: _ Both (R/2 + U2):_ SUBJ. + OBJ. SCORE: (lower extremities)

with great difficulty or unable = Op without difficulty = 6p, with difficulty = 3p, unable = Op without difficulty = 6p, only short time or on high cbair = 3p, unable to use any chair = Op

0 0

(b)

side. Finally, they may occur as compensations for injury or pathology on the opposite or contralaterallinlb (Table 14-6).15 Some of the more common gait abnormalities are discussed next, but this list is by no means inclusive.

The antalgic or painful gait is self-protective and is the result of injury to the pelvis, hip, knee, ankle, or foot. The stance phase on the affected leg is shorter than that on the nonaffected leg, because the patient attempts to remove weight from the affected leg as quickly as possible; therefore, the amount of time on each leg should be noted. The swing phase of the Uflinvolved leg is decreased. The result is a shorter step length on the tmllvolved side, decreased walking velocity, and decreased cadence.33 In addition, the painful region is often supported by one

hand, if it is within reach, and the other arm, acting as a counterbalance, is outstretched. If a painful hip is causing the problem, the patient also shifts the body weight over the painful hip. This shift decreases the pull of the abductor muscles, which decreases the pressure on the femoral head from more than two times the body weight to approximately body weight, owing to vertical instead of angular placement of the load over the hip. Flynn and Widmann have outlined some of the causes of a painful linlp in children60 (Table 14-7).

The arthrogenic gait results from stiffuess, laxity, or deformity, and it may be painful or pain free. If the knee or hip is fused or the knee has recently been removed from a cylinder cast, the pelvis must be elevated by exaggerated
Text continued on page 964

1.

VARIABILITY

- A MEASURE

OF INCONSISTENCY

AND ARRHYTHMICITY 25% of time

OF STEPPING

AND OF ARM MOVEMENTS

o=

fluid and predictably paced limb movements 1 = occasional interruptions (changes in velocity), approximately 2 = unpredictability of rhythm approximately 25%-75% of time 3 = random timing of limb movements 2. GUARDEDNESS - HESITANCY, STEPPING AND ARM SWING SLOWNESS, DIMINISHED

PROPULSION,

AND LACK OF COMMITMENT

IN

o=
1 2 3 3.

= =

good forward momentum and lack of apprehension in propulsion center of gravity of head, arms, and trunk (HAT) projects only slightly in front of push-off, but still good arm-leg coordination HAT held over anterior aspect of foot, and some moderate loss of smooth reciprocation HAT held over rear aspect of stance-phase foot, and great tentativity in stepping - SUDDEN AND UNEXPECTED LATERALLY DIRECTED PARTIAL LOSSES OF BALANCE

STAGGERING

no losses of balance to side 1 = a single lurch to side 2 = two lurches to side 3 = three or more lurches to side 4. FOOT CONTACT - THE DEGREE TO WHICH THE HEEL STRIKES THE GROUND BEFORE THE FOREFOOT very obvious angle of impact of heel on ground 1 = barely visible contact of heel before forefoot 2 = entire foot lands flat on ground 3 = anterior aspect of foot strikes ground before heel 5. HIP ROM - THE DEGREE OF LOSS OF HIP RANGE OF MOTION SEEN DURING A GAIT CYCLE 0= 1= 2 = 3 = 6. obvious angulation of thigh backward during double support (10 degrees) just barely visible angulation backward from vertical thigh in line with vertical projection from ground thigh angled forward from vertical at maximum posterior excursion EXTENSION - A MEASURE OF THE DECREASE OF SHOULDER ROM

o=

o=

SHOULDER 0= 1= 2= 3 =

clearly seen movement of upper arm anterior (15 degrees) and posterior (20 degrees) to vertical axis of trunk shoulder flexes slightly anterior to vertical axis shoulder comes only to vertical axis, or slightly posterior to it during flexion shoulder stays well behind vertical axis during entire excursion - THE EXTENT TO WHICH THE CONTRALATERAL MOVEMENTS OF AN ARM AND

7.

ARM-HEEL STRIKE SYNCHRONY LEG ARE OUT OF PHASE 0= 1= 2= 3=

good temporal conjunction of arm and contralateral leg at apex of shoulder and hip excursions all of the time arm and leg slightly out of phase 25% of the time arm and leg moderately out of phase 25%-50% of the time little or no temporal coherence of arm and leg

Figure 14-15 ~lodified Gait Abnormality Rating Scale (GARS-M). (From Dutton M: Orthopedic examination, ,md intervention, p. 389, New York, 2004, McGraw-Hill.)

C1Jaluation

EVENTS PERIODS TASKS PHASES CYCLE

Initial contact

Load response Mid stance

Heel off

Opposite initial contact Terminal stance Pre swing

Toe off

Feet adjacent Initial swin

Tibia vertical Mid swing

Next i con Terminal swing

Loading response
I

I I

Weiht acceptance

Single-limb support Stance pli1ase Right gait cycle

Limb advancement Swin phase

".

Figure 14-2
Terminology to describe the events of the gait cycle. Initial contact corresponds to the beginning of stance when the foot first contacts the ground at 0% of gait cycle. Load response occurs when the contralateral foot leaves the ground at 10% of gait cycle. Heel offcorresponds to the heel lifting from the ground and occurs at approximately 30% of gait cycle. Opposite initial contact corresponds to the foot contact of the opposite limb, typically at 50% of gait cycle. Toe offoccurs when the foot leaves the growld at 60% of gait cycle. Feet adjacent takes place when the foot of the swing leg is next to the foot of the stance leg at 73% of gait cycle. Tibia vertical corresponds to the tibia of the swing leg being oriented in the vertical direction at 87% of gait cycle. The final event is, again, initial contact, which in fact is the start of the next gait cycle. These eight events divide the gait cycle into seven pet10ds. Loading response, between initial contact and opposite toe off, corresponds to the time when the weight is accepted by the lower extremity, initiating contact with the ground. Midstance is from opposite toe off to heelt1se (10% to 30% of gait cycle). Terminal stance begins when the heel rises and ends when the contralateral lower extremity touches the ground, from 30% to 50% of gait cycle. PresJVing takes place from foot contact of the contralateral limb to toe otf of the ipsilateral foot, which is the time corresponding to dle second double-limb support period ofdle gait cycle (50% to 60% of gait cycle). Initial Slving is fi'om toe off to feet adjacent, when dle foot of the swing leg is next to the foot of the stance leg (60% to 73% of gait cycle). MidSlvingis from feet adjacent to when the tibia of the swing leg is vertical (73% to 87% of gait cycle). Terminal S/l]ing is from a vertical position of dle tibia to immediately before heel contact (87% to 100% of the gait cycle). The first 10% of the gait cycle corresponds to a task of weight acceptancewhen body mass is transferred from onc lower extremity to the other. Single-limb support, from 10% to 50% of the gait cycle] bears dle weight of the body as the opposite limb swings forward. The last 10% of stance phase and dle entire swing phase advance the limb forward to a new location. (Modified from Neumarm DA: Kinesiology of the musculoskeletal system: foundations of physical rehabilitation, St. Louis, p 532, 2002, Mosby.)

Table 14-1 Gait Cycle: Periods and Functions

Initial swing ~lidswing Terminal swing

62-75

75-85
85-100

Support of entire body weight: center of mass moving forward Unloading and preparing for swing (preswing) Foot clearance Limb advances in front of body Limb deceleration, preparation for weight transfer
walking. In Rose

Unloading and preparing swing (preswing) Swing

for

Single limb support Single limb support Single limb support

From Sutherland 27 Baltimore,

DH et aI: Kinematics of normal hwnan 1994, Williams & Wilkins.

J, Gamble

]G, editors: Human

locomotion,

Table 14-5 Gait Deviations Secondary to Specific Impairments* Gait Deviations at the Hip/Pelvis/Trunk Observed Gait Deviation at the Hip/ Pelvis/Trunk Likely Impairment Secondary to Specific Hip/Pelvis/Trunk Selected Pathological Precursors Impairments * Mechanical Rationale and/or Compensations Associated

Lateral trunk lean toward the stance leg; because this movement compensates for a weakness, it is often called a "compensated" Trendelenburg gait and is referred to as a waddling gait if bilateral Excessive downward drop of the conu"alateral pelvis during stance (referred to as a positive Trendelenburg sign if present during single-limb standing) Forward bending of the trunk during mid and terminal stance, as the l~p' is moved over the foot

Marked weakness of the hip abductors Hip pain

Mild weakness of the gluteus medius of the stance leg

Trunk lurches b..ackwa[dand toward the unaffected stance leg from heel off to mid swing Posterior tilt of the pelvis during initial swing Hi,P circun~duction: semicircle movement of the hip during swing-combining hip flexion, hip abduction, and forward rotation of the pelvis Gait Deviations at the Knee Secondary to Specific Knee Impairments* Likely Impail'ment Rapid extension of the knee (knee extensor thrust) immedjately after initial contact Selected Pathological Precursors

This action moves the line of gravity of the trunk behind the hip and reduces the need for hip extension torque Shifting the trunk over the supporting limb reduces the demand on the hip abductors Shifting the trunk over the supporting lower extremity reduces compressive joint forces associated with the action of hip abductors Whereas the Trendelenburg sign may be observed in single-limb standing, a compensated Trendelenburg gait often occurs when there has been severe weakness of the hip abductors Forward u'unk lean is llsed to compensate for lack of hip extension; an alternate adaptation could be excessive lumbar lordosis Keeping the hip at 30 degrees of flexion minimizes intraarticular pressure Lack of hip extension in terminal stance is compensated for by increased lordosis Hip flexion is passively generated by a backward movement of the trunk Abdominals are used during initial swing to advance the swing leg Hip abductors are used as flexors

Mechanical Rationale and/or Compensations

Associated

Depending on the status of the posterior structures of the knee, may occur with or without knee hyperextension

Knee remains extended dming dle loading response, but mere is no extensor mrust

Femoral nerve palsy, L3- L4 compression neuropathy

Flexed position of me knee dming stance and lack of knee extension in terminal swing

Knee extensor weakness (see the two previously described gait deviations) La.,'City of dle posterior and lateralligamentous joint sU'uctmes of the knee Knee flexion contractme > 1 0 (genu flexum) Hamstring overactivity (spasticity) Knee pain and joint effusion Spasticity of knee extensors Knee extension contractme

Knee remains fully extended throughout stance. An associated anterior trunk lean in dle early part of stance moves the line of gravity of the trw1k, slightly antelior to me axis of rotation of me Imee, which keeps me lmee extended wimout action of tlle knee extensors; d1isgait deviation may lead to an excessivestretching of the posterior capsule of me knee and eventual knee hyperextension (genu recurvatwn) during stance Knee is kept in extension to reduce the need for quadriceps activity and associated compressive forces; it may be accompanied by an antalgic gait pattern characterized by a reduced stance time and shorter step lengm Secondary to progressive stretching of the posterior capsule of the knee Rapid varus deviation of the knee during mid stance, typically accompanied by knee hyperextension Associated increase in hip flexion and ankle dorsiflexion dming stance

Traumatic injury or progressive laxity

Upper motor neuron lesion Immobilization (cast, brace) or smgical fusion

Knee is kept in flexion since this is me position of lowest inu'aarticular pressure Compensatory hip hiking and/or hip circumduction could be noted

Gait Deviations at the Ankle/Foot

Secondary to Specific Ankle/Foot Selected Pathological Precursors

Impairments* Mechanical Rationale and/or Compensations Associated

"Foot slap": rapid ankle plantar flexion occurs following heel contact; the name foot slap is derived from the characteristic noise made by me forefoot hitting me ground Entire plantar aspect of me foot touches the ground at initial contact,! followed by normal, passive anlde dorsiflexion dming the rest of stance Initial contact with me ground is made by me forefoot followed by the heel region; normal p:lssiv' ankl' dorsiflexion occurs during stance

Mild weakness of ankle dorsi flexors

Common peroneal nerve palsy and distal peripheral neuropathy ConU110nperoneal nerve palsy and distal peripheral neuropathy Common peroneal nerve palsy and distal peripheral neuropathy

Marked weakness of ankle dorsi flexors

Severe weakness of anlde dorsi flexors

Ankle dorsiflexors have sufficient strengtll to dorsiflex me anlde during swing but not enough to control anlde plantar flexion after heel contact Sufficient strength of the dorsiflexors to partially, but not completely, dorsiflex tlle anlde during swing; normal dorsiflexion occurs during stance as long as the ankle has normal range of motion No active ankle dorsiflexion is possible during swing; normal dorsiflexion occurs during stan .. as long as the ankle ha normal ran 'of' mOl ion

Observed Gait Deviation at the Ankle/Foot Initial contact is made with the forefoot, but the heel never makes contact with the ground during stance

Likely Impairment Heel pain Plantar flexion contracture (pes equinus deformity) or spasticity of ankle plantar flexors Plantar flexion contracture (pes equinus deformity) or spasticity of ankle plantar flexors

Selected Pathological Precursors Calcaneal fracture, plantar fasciitis Upper motor neuron lesion/ cerebral palsy, cerebrovascular accident (CVA) Upper motor neuron lesion (cerebral palsy, CVA) Ankle fusion in a plantar flexed position Congenital or acquired muscular tightness of ankle plantar flexors Peripheral or central nervous system clisorders Excessive surgical lengthening of the Achilles tendon

Mechanical Rationale and/or Compensations

Associated

Purposeful strategy to avoid weight bearing on the heel To maintain the weight over the foot, the knee and hip are kept in flexion throughout stance, leading to a "crouched gait" Knee hyperextension occurs during stance owing to the inability of the tibia to move forward over the foot; hip flexion and excessive forward trunk lean during terminal stance occur to shift the weight of the body over the foot Characteristic bouncing gait pattern

Initial contact is made with the forefoot, and the heel is brought to the ground by a posterior displacement of the tibia

Heel remains in contact with the ground late in terminal stance

Supinated foot position and weight bearing on the lateral aspect of the foot during stance Excessive foot pronation occurs during stance with failure of the foot to supinate in mid stance; normal medial longitudinal arch noted during swing Excessive foot pronation with weight bearing on the medial portion of the foot during stance; the medial longitudinal arch remains absent during swing Excessive inversion and plantar flexion of the foot and ankle occur during swing and at initial contact Ankle remains plantar flexed during swing and can be associated with dragging of the toes, typically called drop foot

Weakness or flaccid paralysis of plantar flexors with or without a fixed dorsiflexed position of the ankle (pes calcaneus deformity) Pes cavus deformity

Excessive ankle dorsiflexion results in prolonged heel contact, reduced push off, and a shorter step length

Rearfoot varus and/or forefoot varus

Congenital or acquired structural deformity

Weakness (paralysis) of ankle invertors Pes planus deformity Pes equinovarus because of spasticity of the plantar flexors and invertors Weakness of dorsiflexors and/ or pes equinus deformity Upper motor neuron lesion (cerebral palsy, CVA)

A high mediallongituclinal arch is noted with reduced midfoot mobility throughout swing and stance Excessive foot pronation and associated flattening of the medial longitudinal arch may be accompanied by a general internal rotation of the lower extremity during stance An overall excessive internal rotation of the lower extremity during stance is possible

Contact with the ground is made with the lateral border of the forefoot Weight bearing on the lateral border of the foot during stance Hip hiking, hip circumduction, or excessive hip and knee flexion of the swing leg or vaulting of the stance leg may be noted to lift the toes off the ground and prevent the toes from dragging during swing

From Ncumnnl1

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Table 14-6 Gait Deviations as a Compensation for a lower Extremity Impairment


Gait Deviations Observed at the HipjPelvis/Trunk as a Compensation for an Impairment Ipsilateral Knee, or Contralateral Lower Extremity of the Ipsilateral Ankle,

Observed Gait Deviation HipjPelvis/Trunk

at the

Forward bending of the trunk during the loading response

Forward bending of the trunk during mid and terminal stance

Excessive hip and knee flexion during swing

Hip hiking (elevation of the ipsilateral pelvis during swing)

Excessive backward horizontal rotation of the pelvis on the side of the stance leg in terminal stance

Often caused by the lack of ankle dorsiflexion of the swing leg; may also be caused by a functionally or anatomically short contralateral stance leg Lack of shortening of the swing leg secondary to reduced hip flexion, reduced knee flexion, and/or lack of ankle dorsiflexion Lack of shortening of the swing leg secondary to reduced hip flexion, reduced knee flexion, and/or lack of ankle dorsiflexion Functionally or anatomically short stance leg Ankle plantar flexor weakness

Trunk is brought forward to move the line of gravity anterior to the a.,xisof rotation of the knee, thereby reducing the need for knee extensors Lack of ankle dorsiflexion during stance results in knee hyperextension and forward trunk lean to move the weight of the body over the stance foot Used to clear the toes of the swing leg

Used to lift the foot of the swing leg off the ground and provide toe clearance

Used to lift the foot of the swing leg off the ground and provide toe clearance

Ankle plantar flexor weakness leads to prolonged heel contact and lack of push off; an increased pelvic horizontal rotation is used to lengthen the limb and maintain adequate step length of the Ipsilateral Ankle,

Gait Deviations Observed Knee Gait Deviation

Observed at the

at the Knee as a Compensation Ipsilateral Hip, or Contralateral

for an Impairment Lower Extremity

Knee is kept in flexion during stance despite the knee having normal range of motion on examination

Impairments at the ankle or the hip including a pes calcaneus deformity, plantar flexor weakness, and hip flexion contracture

Hyperextension of the knee (genu recurvarum) from initial contact to pre swing Antalgic gait

Ankle plantar flexion contracture (pes equinus deformity) or spasticity of ankle plantar flexors Painful stance leg

Lack of ankle dorsiflexion or a short stance leg

of the swing leg

Exaggerated ankle dorsiflexion or hip flexion during stance forces the knee in a flexed position; the contralateral (healthy) swing leg shows exaggerated hip and knee flexion to clear the toes owing to the functionally shorter stance leg Knee must hyperextend to compensate for the lack of forward displacement of the tibia during stance This is characterized by a shorter step length and stance time on the side of the painful lower extremity; it may be accompanied by ipsilateral trunk lean; if hip pain, contralateral trunk lean occurs with knee and foot pain Strategy to increase toe clearance of the swing leg and is typically accompanied by increased hip flexion

Gait Deviations Seen at the Knee as a Compensation for an Impairment of the Ipsilateral Ankle, Ipsilateral Hip, or Contralateral Lower Extremity Observed Gait Deviation at the AnklejFoot Vaulting: compensatory mechanism demonstrated by exaggerated ankle plantar flexion during mid stance; leads to excessivevertical movement of the body Excessivefoot angle during stance that is called toeing-out Reduction of the normal foot ankle during stance that is called toeing-in Any impairment of the contralateral lower extremity that reduces hip flexion, knee flexion, or ankle dorsiflexion during swing Retroversion of the neck of the femur or tight hip external rotators Excessivefemoral anteversion or spasticity of the hip adductors and/or hip internal rotators Strategy used to allow the foot of a functionally long, contralateral lower extremity to clear the ground during swing Foot is in excessivetoeing-out because of excessiveexternal rotation of the lower extremity General internal rotation of the lower extremity

Table 14-7 Differential Diagnosis of Antalgic Gait

Toddler's fracture (tibia or foot) Osteomyelitis, septic arthritis, discitis Arthritis (juvenile rheumatoid arthritis, Lyme disease) Discoid lateral meniscus Foreign body in the foot Benign or malignant turnor

Fracture (especiallyphyseal) Osteomyelitis, septic arthritis, discitis Legg-Calvt- Perthes disease Transient synovitis Osteochondritis dissecans (knee or ankle) Discoid lateral meniscus Sever's apophysitis (calcaneus) Accessory tarsal navicular Foreign body in the foot Arthritis (juvenile rheumatoid arthritis, Lyme disease) Benign or malignant tumor

Stress fracture (femur, tibia, foot, pars interarticularis) Osteomyelitis, septic arthritis, discitis Slipped capital femoral epiphysis Osgood-ScWatter disease or SindingLarsen-Johansson syndrome Osteochondritis dissecans (knee or ankle) Chondromalacia patellae Arthritis (Lyme disease, gonococcal) Accessory tarsal navicular Tarsal coalition Benign or malignant turnor
Academy of Orthopaedic Surgeons,

2001 American Academy of OrthopaedicSurgeons.Reprintedfromthe Journal pp 89-98.

of the American

vot 9(2),

plantar flexion of the opposite ankle and circumduction of the stiffleg (circumducted gait) to provide toe clearance. The patient with this gait lifts the entire leg higher than normal to clear the ground because of a stiff hip or knee (Figure 14-16). The arc of movement helps to decrease the elevation needed to clear the affected leg. Because of the loss of flexibility in the hip, knee, or both, the gait lengths are different for the two legs. When the stiff limb is bearing weight, the gait length is usually smaller.

base (Figure 14-17). The gait of a person with cerebellar ataxia includes a lurch or stagger, and all movements are exaggerated. The feet of an individual with sensory ataxia slap the ground because they cannot be felt. The patien also watches the feet while walking. The resulting gait irregular, jerky, and weaving.

If the patient has poor sensation or lacks muscle coordination, there is a tendency toward poor balance and a broad

Joints of the lower limb may exhibit contracture ifimmobilization has been prolonged or pathology to the join has not been properly cared for. Hip flexion contracture often results in increased lumbar lordosis and extension of the trunk combined with knee flexion to get the foo

Figure 14-16 Arthrogenic (stiff knee or hip) gait. A, Excessive plantar flexion. B, Circumduction.

on the ground. With a lmee lexion contracture, the patient demonstrates exc~ssive ankle _dorsiflexion from late s ng..p.ha..s..c~o early stance phill'e on !he ul1involved leg and earl heel rise on the l1Y.Qlve.d-.sllkin_terminal stance. Plantar flexiQn contracture at the ankle results in knee hyperextension (midstance of affected leg) ans! forward bending of the trunk with hi flexion (midstance to terminal stance of affected leg). Heel rise on the affected leg also occurs earlier. 33

This childhood gait is seen with talipes equinovarus (club foot) (Table 14-8). Weight bearing is primarily on the dorsolateral or lateral edge of the foot, depending on the degree of deformity. The weight-bearing phase on the affected limb is decreased, and a limp is present. The pelvis and femur are laterally rotated to partially compensate for tibial and foot medial rotation.2

I
Figure 14-17 Ataxic gait. (Redrawn from Judge RD. Zuidema GD, Fitzgerald FT: Clinical diagnosis: a physiological approach, p. 438, Boston, 1982, Little, Brown.)

If the gluteus maximus muscle, which is a primary extensor, is weak, the patient thrusts the thorax posteri at initial contact (heel strike) to maintain hip extensio the stance leg. The resulting gait involves a characre - backward lurch of the trunk (Figure 14-18).

Table 14-8 Differential Diagnosis of a Nonantalgic limp


Equinus Gait (Toe-Walking) Legg-Calve- Perthes disease Developmental dysplasia of the hip Slipped capital femoral epiphysis Muscular dystrophy Hemiplegic cerebral palsy Weak gluteus medius Circumduction Vaulting Gait Gait/

Idiopathic tight Achilles tendon Clubfoot (residual or untreated) Cerebral palsy Limb-length discrepancy

Limb-length discrepancy Cerebral palsy Any cause of ankle or knee stiffness

Cerebral palsy Myelodysplasia Charcot- Marie- Tooth disease Friedreich's ata.xia Tibial nerve palsy
Surgeons, vol 9(2),

2001 American Academy of Orthopaedic Surgeons. Reprinted from the Journal pp 89-98.

of the American

Academy

of Orthopaedic

Gluteus Medius (Trendelenburg's) Gait


If the hip abductor muscles (gluteus medius and minimus) are weak, the stabilizing effect of these muscles during stance phase is lost, and the patient exhibits an excessive lateral list in which the thor:Lx is thrust laterally to keep the center of gravity over the stance leg (Figure 14-19). A positive Trendelenburg's sign is also

exhibited (i.e., the contralateral side droops because the ipsilateral hip abductors do not stabilize or prevent the droop). If there is bilateral weakness of the gluteus medius muscles, the gait shows accentuated side-to-side movement, resulting in a wobbling gait or "chorus girl swing. ~ This gait may also be seen in patients with congenital dislocation of the hip and coxa vara (see Table 14-8).

Rgure 14-18 Gluteus maximus gait.

Figure 14-19 Gluteus medius (Trendelenburg's) gait.

The patient with hemiplegic or hemiparetic gait swings the paraplegic leg outward and ahead in a circle (circumduction) or pushes it ahead (Figure 14-20). In addition, the affected upper limb is carried across the trunk for balance. This is sometimes referred to as a neurogenic or flaccid gait.

The neck, trunk, and knees of a patient with parkinsonian gait are flexed. The gait is characterized by shuffling or short rapid steps (marche a petits pas) at times. The arms are held stiffly and do not have their normal associative movement (Figure 14-21). During the gait, the patient may lean forward and walk progressively faster as though unable to stop (festination).61

If the plantar flexor muscles are unable to perform their function, ankle and knee stability are greatly affected. Loss of the plantar flexors results in decrease or absence

Figure 14-21 Parkinsonian gait. (Redrawn from Judge RD, Zuidema GD, Fitzgerald FT: Clinical diagnosis: a physiological approach, p. 496, Boston, 1982, Little, Brown.)

of push -off. The stance phasejs less, .and.the.re is a_sbor.ter step length on the unaffe~ted side.33

The psoatic limp is seen in patients with conditions affecting the hip, such as Legg-Calve- Perthes disease. The patient demonstrates a difficulty in swing-through, and the limp may be accompanied by exaggerated trunk and pelvic movement.33 The limp may be caused by weakness or reflex inhibition of the psoas major muscle. Classic manifestations of this limp are lateral rotation, flexion, and adduction of the hip (Figure 14-22). The patient exaggerates movement of the pelvis and trunk to help move the thigh into flexion.

Figure 14-20 Hemiplegic (hemiparetic) gait. (Redrawn fi'om Judge RD, Zuidema GD, Fitzgerald FT: Clinical diagnosis: a physiological approach, p. 438, 05ton, 1982, Little, Brown.)

If the quadriceps muscles have been injured (e.g., femoral nerve neuropatllY, reflex inhibition, trauma -3strain _ the patient compensates in the trunk and lower leg. Forward flexion of the trunk combined with strong ankle plantar flexion causes the knee to extend (hyperexten _ The knee may be held extended by using the ilio - -

Figure 14-23
Scissors gait. (Redrawn from Judge RD, Zuidema GD, Fitzgerald FT: Clinical diagnosis: a pbysiological approach, p. 439, Boston, 19 .: Litde, Brown.) flex.ion, and abduction of affected

Figure 14-22
Psoatic limp. Note lateral rotation, hip.

band. If the trunk, hip flexors, and ankle muscles cannot perform this movement, the patient may use a hand to extend the knee.33

This gait is the result of spastic paralysis of the hip adductor muscles, which causes the knees to be drawn together so that the legs can be sWlmg forward only with great effort (Figure 14-23). This is seen in spastic paraplegics and may be referred to as a neurogenic or spastic gait.

If one leg is shorter than the other or there is a deformity in one of the bones of the leg, the pa.tiencmay demonstrate a lateral shift to the affected side, and the elvis tilts down on the affected side, creatin ~ limp (Figure 14-24). The patient may also supinate the foot on the affected side to try to "lengthen" the limb. The joints of the unaffected limb may demonstrate exaggerated flexion, or hip hiking may occur during the swing phase to allow the foot to clear the ground.33 The weight-bearing period may be the same for the two legs. How a patient

Figure 14-24
Short leg gai t.

adapts for leg length difference has wide variability.62,63 With proper footwear, the gait may appear normal. This gait may also be termed painless osteogenic gait.

The patient with a steppage gait has weak or paralyzed dorsiflexor muscles, resulting in a drop foot. To compensate and avoid dragging the toes against the ground, the patientlifts the knee higher than normal (Figure 14- 25). At initial contact, the foot slaps on the ground because of loss of control of the dorsiflexor muscles resulting from injury to the muscles, their peripheral nerve supply, or the nerve roots supplying the muscles (see Table 14-8).64 Table 14-9 lists common gait pathologies that can modifYgait and the phase in which the deviation occurS.35

Figure 14-25 Steppage or drop foot gait. (Redrawn from Judge RD, Zuidema GD, FitzgeraJd FT: Clinical diagnosis: a physiological approach, p. 438, Boston, 1982, Little, Brown.)

Table 14-9 Common Gait Pathologies Phase


Midstance through toe off Compensated forefoot or rearfoot varus deformity; uncompensated forefoot valgus deformity; pes planus; decreased ankle dorsiflexion; increased tibial varum; long limb; uncompensated medial rotation of tibia or femur; weak tibialis posterior Compensated forefoot valgus deformity; pes cavus; short limb, LU1compensated lateral rotation of tibia or femur; limited calcaneal eversion; plantar flexed first ray; upper motor neuron muscle balance Excessive tibia vara; forefoot varus; tibialis posterior weakness; excessive lower extremity medial rotation (because of muscle imbalances, femoral anteversion) Contracture; overactiviry of muscles on medial aspect of foot Weak invertors; foot hypermobiliry Heel cord contracture; increased tone 0gastrocnemius and soleus

Excessive valgus Bouncing or exaggerated flexion

plantar

Heel strike to toe off Midstance through toe off

Initial contact

Terminal stance

Figure 14-3 Stance phase of gait.

The load response and midstance instants consist of the single support or single-leg stance, which accounts for the next 40% of the gait cycle. During tIlis period, one leg alone carries the body weight while the other leg goes through its swing phase. The stance leg must be able to hold the weight of the body, and the body must be able to balance on the one leg. In addition, lateral hip stability must be exhibited to maintain balance, and the tibia of the stance leg must advance over the stationary foot. The terminal stance and preswing instants make up the weight-unloading period, which accOlmts for the next 10% of the gait cycle. During tIlls period, the stance leg is unloading the body weight to the contralateral limb and preparing the leg for the swing phase. with the first two instants, both feet are in contact, o double support occurs for the second time during the gait cycle.

Subphases (Instants) of Swing Phase


Initial swing (acceleration) Midswing Terminal swing (deceleration)

The swing phase of gait occurs when the foot is not bearing weight and is moving forward (Figure 14-4). The swing phase allows the toes of the swing leg to clear the floor and allows for leg length adjustments. In addition, it allows the swing leg to advance forward. It makes up approximately 40% of the gait cycle and consists of three ubphases.

, , ,
\

,
\ I I

Acceleration occurs when the foot is lifted off the floor. During normal gait, rapid knee flexion and ankle dorsiflexion occur to allO\,vthe swing limb to accelerate forward. In some padl010gical conditions, loss or alteration of knee flexion and ankle dorsiflexion leads to alterations in gait. The midswing instant occurs when the swing leg is adjacent to the weight-bearing leg, which is in midstance. During the final instant (terminal swing or deceleration), the swinging leg slows down in preparation for initial contact with the floor. With normal gait, active quadriceps and hamstring muscle actions are required. The quadriceps muscles control knee extension, and the hamstrings control the amount of hip flexion. During running or with increased velocity, the stance phase decreases and a float phase or double unsupported phase occurs while the double support phase disappears (Figure 14_5).16,19 Although the single-leg stance phase decreases, the load increases two or three times.20 The motion occurring at each of the joints (pelvis, hip, knee, ankle) is similar for walking and for running, but the required range of motion (ROM) increases widl the speed of the activity. For example hip flexion in walking is about 40 to 45 0, whereas in rurming it is 60 to 75.21

\
I

\
\
\

I \

,~I\..-.._--,
I

'

,_.- ......

",,"'~

Initial swing (acceleration)

Terminal swing (deceleration)

Igure 14-4 wing phase of gait.

Double-leg stance is that phase of gait in which parts of both feet are on the grOlmd. In normal gait, it occurs twice during the gait cycle and represents about 2of dle cycle. This percentage increases the more 10\\ __ one walks; it becomes shorter as walking speed iner (Figure 14-6) and disappears in rWilling.

Steppage gait (exaggerated hip and knee flexion to clear foot) Excessive knee flexion

Excessive knee extension/inadequate knee flexion

Genu recurvatum hyperextension)

(knee

Abnormal internal hip rotation (toe-in gait)

Abnormal external hip rotation (toeout gait)

Decreased hip swing through limp)

(psoatic

Excessive medial or lateral femur rotation (femoral torsion)

Increased base of support (>4 inches/IO cm) Decreased base of support (<2 inches/5 cm) Circumduction

Compensation for knee flexion contracture: inadequate plantar flexor strength; adaptive shortening of dorsiflexors; increased muscle tone of dorsiflexors; pes calcaneus deformity Gastrocnemius and soleus weakness; Achilles tendon rupture; metatarsalgia; hallux rigidus Dorsiflexor weakness; lack oflower limb sensation Dorsiflexor weakness or paralysis; functiona.. leg length discrepancy Hamstring contracture; decreased range 0':motion in ankle dorsiflexion; plantar flex muscle weakness; lengthened limb; hip flexion contracture Pain; anterior trunk deviation/bending; weakness of quadriceps, hyperextension is a compensation and places body weight vector anterior to knee; spasticity of the quadriceps, noted more during the loading response and during initial swing intervals; joint deformity Quadriceps femoris weak or short; compensated hamstring weakness; Achill tendon contracture; habit Adaptive shortening of iliotibial band; weakness of hip external rotators; femoral anteversion; adaptive shortening of hip internal rotators Adaptive shortening of hip external rotators; femoral retroversion; weakness of hip internal rotators Spasticity or contracture of ipsilateral hip adductors; ipsilateral hip adductor weakness; coxa vara Legg-Calve-Perthes disease; weakness or reflex inhibition of psoas major muscle; pain Medial or lateral hamstrings tight, respectively; opposite muscle group weakness; anteversion or retroversion, respectively Abductor muscle contracture; instability; genu valgum; leg length discrepancy; fear oflosing balance Adductor muscle contracture; genu varum Increased limb length; abductor muscle shortening or overuse; stiff hip or knee Increased limb length; hamstring weakness: inadequate hip or knee flexion or ankle dorsiflexion; quadratus lumborum shortening

Vaulting (ground clearance of swinging leg will increase if subject goes up on toes of stance period leg) Inadequate hip flexion

Foot flat to toe off

Functional leg-length discrepancy; occurs on shorter limb side heel strike

vaulting

Acceleration

through

Inadequate hip extension (causes trunk fonvard bending, increased lordosis)

Midstance

through

toe off

Excessive trunk back bending (gluteus maximus gait) Excessive trunk forward bending

Heel strike through Deceleration through

midstance midstance

Excessive trunk lateral flexion (compensated Trendelenburg's Pelvic drop

Foot flat through gait) Foot flat through

heel off heel off

lower cadence than expected for person's age horter stance phase on involved side and decreased swing phase on uninvolved side (shorter stride length on uninvolved side, decrease lateral sway over involved stance linlb, decrease in cadence, decrease in velocity, use of assistive device) tance phase longer on one side

Hip flexor muscle weakness; hip extensor muscle shortening; increased limb lengthhip joint arthrosis Hip flexion contracUlre; hip extensor muscle weakness; iliotibial band contracture; hip flexor spasticity; pain Inability to extend hip; hip flexion contracUlre or hip ankylosis Hip extensor or flexor muscle weakness; hip pain; decreased range of motion of knee Quadriceps femoris and gluteus maxim us weakness; decreased ankle dorsiflexion; hip flexion contracture Gluteus medius weakness; hip pain; unequal leg length; hip pathology; wide base Contralateral gluteus medius weakness; adaptive shortening of quadraUls lumborum; contralateral hip adductor spasticity Adaptively shortened/spasticity of hip flexors on same side; limited hip joint flexion Generalized weakness; pain; joint motion restrictions; poor volwltary motor control Antalgic gait resulting from painful injury to lower limb and pelvic region

Pain; lack of trunk and pelvic rotation; weakness oflower limb muscles; restrictions in lower linlb joints; poor muscle control; increased muscle tone

dapted from GiaUonardo LM: Gait. In Myers RS, editor: Sat~nders manual of physical thetapy practice, p 1112, Philadelphia, 1995, WE aunders; and Dutton M: CJt.thopedic examination, evaluation and intervention, New York, 2004, McGraw-Hill.

To enhance this text and add value for the reader, all references have been incorporated into a CD-ROM that is provided with this text. The reader can view the reference source and access it online whenever possible. There are a total of 64 cited references and other general references for this chapter.

0
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10

20

30

40

50

60

70

80

90

100

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Stance (65%)

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Foot off

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Swing (35%)

Right heel strike


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Left heel strike

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Double limb unsupported
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Mid stance

Toe off
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Right heel strike

Figure 14-5
Comparison of the phases of the walking and running cycles.

Right heel initial contact


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Left pre-swing

,,

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Left heel initial contact


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Right pre-swing

,, ,,

Right heel initial contact

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Left pre-swing

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0%

Right single support


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60%

Left single support

,,,
100% Right swing phase (40%)

15% Right stance phase (60%) 0% Left swing phase (40%)

45%

r
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I

40%

55% Left stance phase (60%)

85%

100%

Time, percent of cycle

Figure 14-6
TIme dimensions of the walking cycle. (Adapted Baltimore, 1981, Williams & Wilkins.) from Inman VT, fullston

HT,

Todd F: Human

walking, p. 26,

The single-leg stance phase of gait occurs when only one leg is on the ground; this occurs twice during the normal gait cycle and takes up approximately 30% of the cycle.

Gait Parameters That are Significantly Decreased in Women Compared with Men22
Velocity Stride and step length Proportional distance of center of gravity from ground Sagittal hip motion Knee flexion in initial swing Width of base of support Vertical head excursion Lateral head excursion Shoulder sagittal motion Elbow flexion

The parameters that follow and their values are considered normal for a population between the ages of 8 and 45 years. It should be pointed out, however, that a relatively normal gait pattern is seen in persons as young as 3 years of age.2 There are, however, differences between individuals of the same sex and between men and women.23 For the majority of the population outside of these ages, there are alterations caused by neurological development, balance control, aging, changes in limb length, and maturation.2 For example, with maturity, walking velocity and step length increase, and cadence decreases.24 It is also important to evaluate gait on the basis of normal gait for someone the same age. This is especially true for children.

The normal base width, which is the distance between the two feet, is 5 to 10cm (2 to 4 inches; Figure 14-7). If the base is wider, the examiner may suspect some pathology (e.g., cerebellar or inner ear problems) that results in poor balance, a condition such as diabetes or peripheral neuropathy that may indicate a loss of sensation, or

Figure 14-7
Normal base width.

a musculoskeletal problem (e.g., tight hip abductors). In the first two cases, the patient tends to have a wider base to maintain balance. With increased speed, the base width normally decreases to zero, and in some cases, crossover occurs, in which one foot lands where the other should and vice versa. Such crossover can lead to gait alterations and other problems.2s

Step length, or gait length, is the distance benveen successive contact points on opposite feet (see Figure 14-1). ormally, this distance is about 72 cm (28 inches) being relatively constant for each individual (i.e., step length is commonly related to preferred walking speed)IS,26and should be equal for both legs. It varies with age and sex, with children taking smaller steps than adults and females taking smaller steps than males.20 Height also has an effect: a taller person takes larger steps. Step length tends to decrease with age, fatigue, pain, and disease. If step length is normal for both legs, the rhythm of walking will be smooth. If there is pain in one limb, the patient attempts to take weight off that limb as quickly as possible, altering the rhythm.

Normal Gait Parameters


Base width: Step length: Stride length: Cadence: Gait speed: 5-10cm approximately 72 cm approximately 144 cm 90-120 steps/min approximately 1.4 m/sec

Figure 14-8 Pelvic shift. Numbers indicate that one lateral or vertical shift occurs and then the other; they do not occur at the same time. 1 = right lateral shift; 2 = left lateral shift; 3 = right vertical shift; 4 = left verti= shift.

the weight-bearing limb, facilitating the action of the hi adductors. If these muscles are weak, a Trendelenburg' gait results (see Figure 14-18).

Stride length is the linear distance in the plane of progression between successive points of foot-to-floor contact of the same foot. The stride length is normally about 144 cm (56 inches) and in reality is one gait cycle. ISStride length, like step length, decreases with age, pain, disease, and fatigue.17,27 The age changes are often the result of decreased walking pace or speed.27,28

Lateral pelvic shift, or pelvic list, is the side-to-side movement of the pelvis during walking. It is necessary to center the weight of the body over the stance leg for balance (Figure 14-8). The lateral pelvic shift is normally 2.5 to Scm (1 to 2 inches). It increases if the feet are further apart. The pelvic list causes relative adduction of

Vertical pelvic shift keeps the center of gravity from moving up and down more than S cm (2 inches) during normal gait. By means of a vertical pelvic shift, the high point occurs during midstance and the low poin during initial contact; the height of these points may increase during the swing phase if the knee is fused or does not bend because of protective spasm or swelling. The head is never higher during normal gait than it i when the person is standing on both feet. Therefore if a person can stand in an opening, he or she should be able to move through the opening without hitting the head.7 On the swing phase, the hip is lower on the swing side, and the patient must flex the knee and dorsiflex the foot to clear the toe. This action shortens the extremity length at midstance and decreases the center of gravity rise.

of the center of gravity describe a figure eight, occupying a 5-cm (2-inch) square within the pelvis during walking. The vertical clisplacement, which describes a smooth sinusoidal curve during walking, can be observed from the side. The patient's head descends during weightloading and weight-unloading periods and rises during single-leg stance.

The normal cadence is between 90 and 120 steps per mi.nute.29.31 The cadence of women is usually 6 to 9 steps per minute higher tl1an that of men.31 Witl1 age, the cadence decreases. Figure 14-10 illustrates tl1e cadence of normal gait from heel strike to toe off showing the changing weight clistribution. With pathology or deformity (e.g., a cavus foot), this weight-bearing pattern may be altered. As the pace of walking increases, the stride widtl1 increases, and the toeing-out angle decreases. Gait speed is about lAm/sec (3mph)J5

Normal Pattern of Gai{6-11,15,29,32,33


Stance Phase
gure 14-9
civic rotation. Left: forward pelvic rotation is illustrated.

elvic rotation is necessary to lessen the angle of the : mur with the floor, and, in so doing, it lengthens the ur (Figure 14-9). The rotation decreases the ampli~ de of clisplacement along the path traveled by the cenof gravity and thereby decreases the center-of-gravity . - . There is a total of 8 pelvic rotation, with 4 forward the swing leg and 4 posteriorly on the stance leg. -0 maintain balance, the thorax rotates in the opposite -' ection. When the pelvis rotates clockwise, the thorax tates counterclockwise, and vice versa. These concurnt rotations provide counterrotation forces and help xgulate the speed of walking. In the lower limb, rotation is evident at each joint. -=ne farther the joint is from the trunk, the greater the ount of rotation. For example, rotation in the tibia is ee times greater than rotation in the pelvis?

As previously mentioned, there are five instants involved during the stance phase of gait. These are now described in order of occurrence. This phase is tl1e closed kinetic chain phase of gait. The action occurring at the various joints causes a chain reaction because of the stresses put on the joints and supporting structures with weight bearing. The foot becomes the fixed stable segment, and alterations occur from the foot up, with the joints of the foot adapting first, followed by those of the ankle, knee, hip, pelvis, spine, and finally the upper limb, which acts as a counterbalance to movement in the lower limb.34 The relations between the joints are constantly changing . Table 14-2 summarizes tl1e movement at the hip, knee, ankle, and foot during the stance phase.35

Initial Contact (Heel Strike)


Initial contact occurs when the limb first strikes the ground. Normally, tl1is occurs when the heel strikes and tl1e limb is being prepared to take weight. During the initial contact, the pelvis is level and medially rotated on the side of initial contact, whereas the trunk is aligned between the two lower limbs. The hip is flexed 30 to 49 and is medially rotated; tl1e knee is slightly flexed 0 extended; the tibia is laterally rotated; the ankle is at 90= with tl1e foot supinated; and the hindfoot is everted. At this instant, tl1ere is little force going through the limb, If pain occurs in the heel at this time, it may be ca by a heel spur, bone bruise, heel fat-pad bruise or sitis. This pain may cause increased fIexion of the with early plantar flexion to relieve the stress or pn::ss:~

_ormally, in the standing position, the center of grav, is 5 cm (2 inches) anterior to the second sacral verte; it tends to be slightly higher in men than in women cause men tend to have a greater body mass in the ulder area. The vertical and horizontal displacements

Figure 14-10 The cadence of gait. A, Normal foor. B, Cavus foor. (From Viladot A: Patologia del Antepie, Barcelona, 197Ediciones Toray, SA.)

Table 14-2 Summary of Joint Motions at the Hip, Knee, Tibia, Foot, and Ankle during the Stance Phase of Gait Hip
Kinetic Motion Internal 20 to 40 of hip flexion moving toward extension; slight adduction and lateral rotation Reaction force in front of joint; flexion moment moving toward extension; forward pelvic rotation Forces

Hip moving into extension, adduction, medial rotation

Moving through neutral position; pelvis rotating posteriorly

Reaction force posterior to hip joint; extension moment

10 to 15 extension of hip abduction, lateral rotation Moving toward 10 extension, abduction, lateral rotation

Extension moment decreasing after double-limb support begins Decrease of extension moment

Gluteus maximus and hamstrings working eccentrically to resist flexion moment; erector spinae working eccentrically to resist forward bend Gluteus maximus and hamstrings contracting concentrically to bring hip into extension; erector spinae resisting trunk flexion Iliopsoas working eccentrically to resist extension; gluteus medius contracting in reverse action to stabilize opposite pelvis Iliopsoas activity continuing

Adductor magnus working eccentrically to control or stabilize pelvis; iliopsoas activity continuing

Kinematic Phase Heel strike Knee In full extension before heel contact; flexing as heel strikes floor In 20 flexion moving toward extension

Motion Tibia Slight lateral rotation External Forces

Kinetic Motion Internal Forces

Foot flat

Medial rotation

Rapidly increasing reaction forces behind knee joint causing flexion moment Flexion moment

Midstance

In 15 flexion moving toward extension

Neutral

Maximum flexion moment

Heel off

In 4 flexion moving toward extension Moving from near full extension to 40 flexion

Lateral rotation

Toe off

Lateral rotation

Reaction forces moving anterior to joint; extension moment Reaction forces moving posterior to joint as knee flexes; flexion moment

Quadriceps femoris contracting eccentrically to control rapid knee flexion and to prevent buckling After foot is flat, quadriceps femoris activity becoming concentric to bring femur over tibia Quadriceps femoris activity decreasing; gastrocnemius working eccentrically to control excessive knee extension Gastrocnemius beginning to work concentrically to start knee flexion Quadriceps femoris contracting eccentrically

Kinematic Phase Heel strike Foot Supination (rigid) at heel contact

Motion Ankle Moving into plantar flexion External Forces

Kinetic Motion Internal Forces

Reaction forces behind joint axis; plantar flexion moment at heel strike Maximum plantar flexion moment; reaction forces beginning to shift anterior, producing a dorsiflexion moment Slight dorsiflexion moment

Foot flat

Pronation, adapting to support surface

Plantar flexion to dorsiflexion over a fixed foot

Dorsiflexors (tibialis anterior, extensor digitorum longus, and extensor hallucis longus) contracting eccentrically to slow plantar flexion Dorsiflexion activity decreasing; tibialis posterior, flexor hallucis longus, and flexor digitorum longus working eccentrically to control pronation Plantar flexor muscles (gastrocsoleus and peroneal muscles), activated to control dorsiflexion of the tibia and fibula over a fixed foot, contracting eccentrically Plantar flexor muscles beginning to contract concentrically to prepare for push off Plantar flexor muscles at peak activity but becoming inactive as foot leaves ground

Midstance

Neutral

3 of dorsiflexion

Heel off

Toe off

Supination as foot becomes rigid for push-off Supination

15 dorsiflexion toward plantar flexion 20 plantar flexion

Maximal dorsiflexion moment Dorsiflexion moment

Modified from Giallonardo LM: Gait. In Myers RS, editor: Satmders manual afphysical therapy practice, pp 1108-1109, Philadelphia, 1995 WE Saunders.

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