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Gait
Original Editors - Karsten De Koster
Top Contributors - Karsten De Koster, Naomi O'Reilly, Daphne Jackson and Scott
Buxton
Contents
[hide]
1 Introduction
2 Definitions
3 The Gait Cycle
4 Phases of the Gait Cycle
4.1 Heel Strike
4.2 Foot Flat
4.3 Midstance
4.4 Heel Of
4.5 Toe Of
4.6 Early Swing
4.7 Mid Swing
4.8 Late Swing
5 Anatomical Considerations
6 Pathological Gait
6.1 Musculoskeletal Causes
6.2 Hip Pathology

6.3 Knee Pathologies

6.4 Ankle Pathologies
6.5 Leg Length Discrepancy
6.6 Antalgic Gait
6.7 Common Neurological Causes of Pathological Gait
7 Gait Analysis
8 Function of the Foot
9 Clinical Bottom Line
10 Recent Related Research (from Pubmed)
11 Read 4 Credit
12 References
Introduction
Bipedal walking is an important characteristic of humans.[1] This page will present
information about the diferent phases of the gait cycle and important
functions of the foot while walking.
Definitions
Sandra J. Shultz describes gait as[2]: ...someones manner of ambulation or
locomotion, involves the total body. Gait speed determines the
contribution of each body segment. Normal walking speed primarily
involves the lower extremities, with the arms and trunk providing
stability and balance. The faster the speed, the more the body
depends on the upper extremities and trunk for propulsion as well as
balance and stability. The legs continue to do the most work as the
joints produce greater ranges of motion trough greater muscle
responses. In the bipedal system the three major joints of the lower
body and pelvis work with each other as muscles and momentum
move the body forward. The degree to which the bodys center of
gravity moves during forward translation defines efficiency. The
bodys center moves both side to side and up and down during gait.

The gait cycle is a repetitive pattern[3] involving steps and strides. A step is one
single step, a stride is a whole gait cycle. The step time is the time
from one foot hitting the floor to the other foot hitting the floor.[3]
Step width can be described as the mediolateral space between the
two feet.[3]
There are some diferences between the gait and run cycle - the gait cycle is one
third longer in time, the ground reaction force is smaller in the gait
cycle (so the load is lower), and the velocity is much higher.[4] (D) In
running, there is also just one stance phase while in stepping there
are two. Shock absorption is also much larger in comparison to
walking.[4] This explains why runners have more overload injuries.[4]
The Gait Cycle
The sequences for walking that occur may be summarized as follows:[1]
Registration and activation of the gait command within the central nervous
system
Transmission of the gait systems to the peripheral nervous system
Contraction of muscles
Generation of several forces
Regulation of joint forces and moments across synovial joints and skeletal
segments
Generation of ground reaction forces
Classification of the gait cycle involves two main phases: the stance phase and the
swing phase. The stance phase occupies 60% of the gait cycle while
the swing phase occupies only 40% of it.[3] Gait involves a
combination of open- and close-chain activities.[2]
A more detailed classification of gait recognizes six phases:[2][3]
Heel Strike
Foot Flat

Mid-Stance
Heel-Of
Toe-Of
Mid-Swing
Figure

1:

Snijders

CJ

et

al,

Het

Gaan,

(https://eduweb.hhs.nl/~bergwandelen/onderzoek.htm), 1995.
An alternative classification of gait involves the following eight phases:[3][5]
Initial Contact
Loading Response
Midstance
Terminal Stance
Pre swing
Initial Swing
Mid Swing
Late Swing
Figure 2: Demos, Gait analysis, (http://www.ncbi.nlm.nih.gov/books/NBK27235/),
2004.
Stance phase begins with the heel strike - this is the moment when the heel begins
to touch the ground but the toes do not yet touch.[2] In the midstance
phase, we can see settlement of the foot at the lateral border. During
the

change

from

mid

stance

to

toe

of

stance,

the

metacarpohalanges contract.[5] The toe-of phase is also named the

propulsive phase.
When the stance phase ends, the swing phase begins. This phase is the phase
between the toe of phase and the heel strike phase. In the swing
phase we can recognize two extra phases - acceleration and
declaration.[5] The acceleration phase goes from toe-of to midswing,
while

declaration

goes

from

midswing

to

heel

strike.

In

the

acceleration phase, the swing leg makes an accelerated forward

movement with the goal of propelling the body weight forward. The
declaration phase brakes the velocity of this forward body movement
in order to place your foot down with control. Between these two
phases, the mid-swing phase occurs. In this phase, both feet are
under the body, with the heel next to each other.[6]
Phases of the Gait Cycle
Heel Strike
Heel strike, also known as initial contact, is a short period which begins the moment
the foot touches the ground and is the first phase of double support.
[2] 30 flexion of the hip and full extension in the knee is observed.
The ankle moves from a neutral (supinated 5) position into plantar
flexion.[2][3] After this, knee flexion (5) begins and increases, just as
the plantar flexion of the heel increased.[3] The plantar flexion is
allowed by eccentric contraction of the tibialis anterior, extension of
the knee is caused by a contraction of the quadriceps, flexion is
caused by a contraction of the hamstrings, and the flexion of the hip is
caused by the contraction of the rectus femoris.[3]
Foot Flat
In foot flat, or loading response phase, the body absorbs the impact of the foot by
rolling in pronation.[2] The hip moves slowly into extension, caused by
a contraction of the adductor magnus and gluteus maximus muscles.
The knee flexes to 15 to 20 of flexion. [3]Ankle plantar flexion
increases to 10-15.[2][3]
Midstance
In midstance the hip moves from 10 of flexion to extension by contraction of the
gluteus medius muscle.[3] The knee reaches maximal flexion and then
begins to extend. The ankle becomes supinated[2] and dorsiflexed
(5), which is caused by some contraction of the triceps surae
muscles.[2] During this phase, the body is supported by one single

leg. At this moment the body begins to move from force absorption at
impact to force propulsion forward.[2]
Heel Of
Heel of begins when the heel leaves the floor. In this phase, the body weight is
divided over the metatarsal heads.[2] Here can we see 10-13 of hip
hyperextension, which then goes into flexion. The knee becomes
flexed (0-5)[3] and the ankle supinates and plantar flexes.[3]
Toe Of
In the toe-of/pre-swing phase, the hip becomes less extended. The knee is flexed
35-40 and plantar flexion of the ankle increases to 20.[2][3] In toeof, like the name says, the toes leave the ground.[3]
Early Swing
In the early swing phase the hip extends to 10 and then flexes due to contraction
of the iliopsoas muscle[3] 20 with lateral rotation.[2][3] The knee
flexes to 40-60, and the ankle goes from 20 of plantar flexion to
dorsiflexion, to end in a neutral position.[2]
Mid Swing
In the midswing phase the hip flexes to 30 (by contraction of the adductors) and
the ankle becomes dorsiflexed due to a contraction of the tibialis
anterior

muscle.[3]

The

knee

flexes

60

but

then

extends

approximately 30 due to contraction of the sartorius muscle.[2][3]

This extension is caused by the quadriceps muscles.[2][3]
Late Swing
The late swing/declaration phase begins with hip flexion of 25-30, a locked
extension of the knee and a neutral position of the ankle.[2]
Anatomical Considerations
The gait cycle involves movement in each part of the leg (and the body).

In the pelvic region there is an anterior-posterior displacement, which alternates

from left to right. This displacement facilitates anterior movement of
the leg. At each side, there is an anterior-posterior displacement of 45.[2][3][5]
In the frontal plane, varus movement is observed in the foot between heel-strike
and

foot-flat

and

between

heel-of

and

toe-of.

Some

valgus

movement is also observed between foot-flat and heel of in the

feet.In the hip, some varus movement is observed in lateral
movements. When the abductors are too weak, a Trendelenburg gait
can be observed.[2][5]
It is important to recognize that the entire body moves while walking. A disorder in
any segment of the body can have consequences on the individual's
gait pattern, like a reduced knee flexion range in patients with a
reconstructed ACL.[7]
Pathological Gait
Pathological gait is an altered gait pattern due to deformities, weakness or other
impairments, for example, loss of motor control or pain[8]. Alterations
can broadly be divided into neurological or musculoskeletal causes[9].
Musculoskeletal Causes
Pathological gait patterns resulting from musculoskeletal are often caused by soft
tissue imbalance, joint alignment or bony abnormalities. Infliction of
these on one joint often then impacts on other joints, afecting the
gait pattern as a result[9]. The common deviation can be categorised
broadly as[9]:
Hip Pathology
Knee pathology
Foot and ankle pathology
Leg length discrepancy
Pain

Hip Pathology
Arthritis is a common cause of pathological gait. An arthritic hip has reduced range
of movement during swing phase which causes an exaggeration of
movement in the opposite limb hip hiking[9].
Excessive Hip Flexion can significantly alter gait pattern most commonly due to;
Hip flexion contractures IT band contractures, Hip flexor spasticity,
Compensation for excessive knee flexion and ankle DF, Hip pain
Compensation for excess ankle plantar flexion in mid swing[10]. The
deviation of stance phase will occur mainly on the afected side. The
result is forward tilt of the trunk and increased demand on the hip
extensors or increased lordosis of the spine with anterior pelvic tilt. A
person with reduced spinal mobility will adopt a forward flexion
position in order to alter their centre of gravity permanently during
gait[10].
Hip Abductor Weakness. The abductor muscles stabilise the pelvis to allow the
opposite leg to lift during the swing phase. Weak abductor muscles
will cause the hip to drop towards the side of the leg swinging forward.
This is also known as Trendelenburg gait[11]
Hip Adductor Contracture. During swing phase the leg crosses mid line due to the
weak adductor muscles, this is known as scissor gait[11]
Weak Hip Extensors will cause a person to take a smaller step to lessen the hip
flexion required for initial contact, resulting in a lesser force of
contraction required from the extensors. Overall gait will be slower to
allow time for limb stabilisation. Compensation is increased posterior
trunk positioning to maintain alignment of the pelvis in relation to the
trunk[10][11]

Hip Flexor Weakness results in a smaller step length due to the weakness of the
muscle to create the forward motion. Gait will likely be slower and
may result in decreased floor clearance of the toes and create a
drag[10]

Knee Pathologies
Weak Quadriceps. The quadriceps role is to eccentrically control the knee during
flexion through the stance phase. If these muscles are weak the hip
extensors will compensate by bringing the limb back into a more
extended position, reducing the amount of flexion at the knee during
stance phase. Alternatively heel strike will occur earlier increasing the
ankle of plantar flexion at the ankle, preventing the forward
movement of the tibia, to help stabilise the knee joint[10][11].
Severe Quadriceps Weakness or instability at the knee joint will present in
hyperextension during the initial contact to stance phase. The knee
joint will snap back into hyperextension as the body weight moves
forwards over the limb[10][11]
Knee Flexion Contraction will cause a limping type gait pattern. The knee is
restricted in extension, meaning heel strike is limited and step length
reduced. To compensate the person is likely to toe walk during
stance phase. Knee flexion contractures of more than 30 degrees will
be obvious during normal paced gait. Contractures less then this will
be more evident with increased speeds[10][9][11].

Ankle Pathologies
Ankle Dorsiflexion Weakness results in a lack of heel strike and decreased floor
clearance. This leads to an increased step height and prolonged swing
phase[10][11].

Calf Tightening or Contractures due to a period of immobilisation or trauma will

cause

reduced

heel

strike

due

to

restricted

dorsiflexion.

The

compensated gait result will be toe walking on stance phase,

reduced step length and excessive knee and hip flexion during swing
phase to ensure floor clearance[10][9].

Leg Length Discrepancy

Leg length discrepancy can be as a result of an asymmetrical pelvic, tibia or femur
length or for other reasons such as a scoliosis or contractures. The
gait pattern will present as a pelvic dip to the shortened side during
stance phase with possible toe walking on that limb. The opposite leg
is likely to increase its knee and hip flexion to reduce its length[9].

Antalgic Gait
Antalgic gait due to knee pain presents with decreased weight bearing on the
afected side. The knee remains in flexion and possible toe weight
bearing occurs during stance phase[9]
Antalagic gait due to ankle pain may present with a reduced stride length and
decreased weight bearing on the afected limb. If the problem is pain
in the forefoot then toe of will be avoided and heel weight bearing
used. If the pain is more in the heel, toe weight bearing is more likely.
General ankle pain may result in weight bearing on the lateral
border[10][9][11].
Antalgic gait due to hip pain results in reduced stance phase on that side. The trunk
is propelled quickly forwards with the opposite shoulder lifted in an
attempt to even the weight distribution over the limb and reduce
weight bearing. Swing phase is also reduced[10][9].

Common Neurological Causes of Pathological Gait

Hemiplegic Gait, often seen as a result of a stroke. The upper limb is in a flexed
position, adducted and internally rotated at the shoulder. The lower
limb is internally rotated, knee extended and the ankle inverted and
plantar flexed. The gait is likely to be slow with circumduction or hip
hitching of the afected limb to aid floor clearance[12][9].
Diplegic Gait. Spasticity is normally associated with both lower limbs. Contractures
of the adductor muscles can create a scissor type gait with a
narrowed base of support. Spasticity in the lower half of the legs
results in plantarflexed ankles presenting in tip toe walking and often
toe dragging. Excessive hip and knee flexion is required to overcome
this[12][9].
Parkinsonian Gait often seen in Parkinsons disease or associated with conditions
which cause parkinsonisms. Rigidity of joints results in reduced arm
swing for balance. A stooped posture and flexed knees are a common
presentation. Bradykinesia causes small steps which are shuffling in
presentation. There may be occurrences of freezing or short rapid
bursts of steps known as festination and turning can be difficult[12]
[9].
Ataxic Gait is seen as uncoordinated steps with a wide base of support and
staggering/variable foot placement. This gait is associated with
cerebellar disturbances and can be seen in patients with longstanding
alcohol dependency[12][9]
People with 'Sensory'Disturbances may present with a sensory ataxic gait.
Presentation is a wide base of support, high steps and slapping of feet
on the floor in order to gain some sensory feedback. They may also

need to rely on observation of foot placement and will often look at

the floor during mobility due to lack of proprioception[12][9].
Myopathic Gait. Due to hip muscular dystrophy, if it is bilateral the presentation will
be a waddling gait, unilaterally will present as a Trendelenburg
Gait[12].
Neuropathic Gaits. High stepping gait to gain floor clearance often due to foot
drop[12]
Below are links to videos demonstrating normal gait and various gait abnormalities:

Gait Analysis
The analysis of the gait cycle is important in the biomechanical mobility
examination to gain information about foot dysfunction in dynamic
movement and loading.[13] When analyzing the gait cycle, it is best
to examine one joint at time.[2] Objective and subjective methods can
be used.[14][15] (A1) An objective approach is quantitative and
parameters like time, distance, and muscle activity will be measured.
Some objective methods to assess the gait cycle are:[16][15]
Video Analysis and Treadmill
Electronic and Computerized Apparatus
Electronic Pedometers
Satellite Positioning System[14] (A1)
Qualitative methods to assess and analyze gait include: [15]
Rancho Los Amigos Hospital Rating List[17] (D)
Ten Meter Walking Test[18](A1)
6 Minute Walking Test
2 Minute Walking Test

Dynamic Gait Index

Emory Functional Ambulation Profile[19] (B)
Timed Up and Go Test[20] (B), This test is statistically associated with falling in
men, but not in women (A2).
Functional Ambulation Categories[21] (D)
Tinetti-Test[22] (A2)
Function of the Foot
The foot requires sufficient mobility and stability for all of its functions. Mobility is
necessary for absorbing the ground reaction force of the body.[23]
Subtalar pronation has a shock absorbing efect during initial heel
contact.[23][24][13][25] Pronation is also necessary to make rotation
of the leg possible and to absorb the impact of this rotation. Subtalar
pronation plays a role in shock absorption through eccentric control of
the supinators.[23] On the other side, the joint of Chopart becomes
unlocked so that the forefoot can stay loose and flexible.[24] In
midstance, the foot needs mobility to adapt to variation in surfaces.
[23][24][13][25]
Foot stability is necessary to provide a stable base for the body. The foot needs the
capacity to bear body weight and act as a stable lever to propel the
body in forward.[23][24][13][25] This function requires pronation
control of the subtalar joint.[24][13][25]
Normal foot function provides the foot with the capacity to transform at the right
time from a mobile adapter to a rigid lever. The foot needs sufficient
mobility to move into all the positions of the gait cycle while
maintaining mobility and stability.[26][23] Physiological mobility is
essential, because if mobility was too large, the foot would not have
the capacity to be stable. When this condition is fulfilled, the joint can
support standing in the stable maximally close packed position.[23]
[24] When the normal transition of the two functions isnt normal
many overload injuries can be observed, like in the foot, under leg,

upper leg but also in the lower back.[24][13][25] Therefore the three
phases of ground contact have to fall in the normal time interval,
otherwise

some

compensation

mechanisms

(example:

genu

recurvatum in cases of reduced dorsiflexion) will be used, which cause

overuse syndromes.[24][27](Example: chondromalacia, shinsplints...)
In the transition from midstance to propulsion phase, the mechanisms often fail. The
transition from eversion to inversion is facilitated by the tibialis
posterior muscle.[23] Hereby the muscle is stretched like a spring and
potential energy is stored.[23] At the end of the midstance, the
muscle passes from eccentric to concentric work and the energy is
released. The tibialis posterior muscle then causes abduction and
dorsiflexion of the caput tali in which the hindquarter everted.[23] At
the same time, the muscle peroneus longus, at the end of the
midstance, will draw the forefoot with a plantar flexion of the first toe.
[23] This is how the forefoot becomes stable.[23]
When the forefoot moves in the propulsion phase, the windlass phenomena starts.
When the dorsiflexion of the metatarsophalangal joints begins the
plantar fascia undergoes stress, so the os calcaneus becomes vertical
and teared in inversion. Like this, the hindquarter rests in inversion in
the unwinding of the forefoot.[23]
When there are some abnormalities in the normal gait cycle of functions of the
body, some functional ortheses can be used.[24][13][25] This orthese
have the capacity to correct the biomechanical function of the foot.
[24][13][25] In contrast, insoles only support the arch of the foot.
Reduced or limited mobility in the lower limbs can be caused by a
articular

limitation.[24][13][25]

In

these

cases

some

classic

mobilizations or mobilizations according to manual therapy can be

designated.[24][13][25] When the cause is a muscle shortening some
stretching can be designated. Also, good (running) shoes are
indicated.[21] (D)
Clinical Bottom Line

A good knowledge of anatomy and biomechanics is important to understand the

diferent phases of the gait cycle. When you know the normal pattern,
you can see whats going wrong.