DR.

SYED ALAM ZEB ORTHOPAEDIC B HMC

Dedicated lower extremity Defines the way we are, our attitude and basis of our personality. Or how we carry our selves.

title Section I Section II INTRODUCTION PHASES COMPONENTS OF GAIT PHASES MEASURABLE DETERMINENTS Section III EFFECT OF PATHOLOGY OVER A GAIT COMPONENT ROM & GAIT MUSCLES ACTING IN GAIT CYCLE GAIT CYCLE AND FOOT Section IV SOME IMPORTANT GAIT ABNORMALITIES

Normal Gait =

Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity series of controlled falls

Gait Cycle =
Single sequence of functions by one limb Begins when reference foot contacts the ground Ends with subsequent floor contact of the same foot

Step Length =
Distance between corresponding successive points of heel contact of the opposite feet Rt step length = Lt step length (in normal gait)

Stride Length =

Distance between successive points of heel contact of the same foot Double the step length (in normal gait)

Cadence =
Number of steps per unit time Normal: 100 115 steps/min Cultural/social variations

Velocity =
Distance covered by the body in unit time Usually measured in m/s Instantaneous velocity varies during the gait cycle Average velocity (m/min) = step length (m) x cadence (steps/min)

Comfortable Walking Speed (CWS) =

Least energy consumption per unit distance Average= 80 m/min (~ 5 km/h , ~ 3 mph)

Stance phase Swing phase

Phases:
(1)

Stance Phase: reference limb in contact with the floor

(2) Swing Phase: reference limb not in contact with the floor

Time Frame:
A. Stance vs. Swing:

Stance phase Swing phase

= =

60% of gait cycle 40% 40% of gait cycle 20%

B. Single vs. Double support:

Single support= Double support=

With increasing walking speeds:

Stance phase: Swing phase: Double support: decreases increases decreases

Running:
By definition: walking without double support Ratio stance/swing reverses Double support disappears. Double swing develops

Stride (100%) Stance (60%)

Loading
Response (0 - 10%)

Swing (40%)
PreSwing
(50-60%)

Midstance (10 - 30%)

Terminal Stance (30-50%)

Initial Swing
(60-73%)

Midswing (73-87%)

Terminal Swing (87-100%)

Double Support (10%)

Double Support (10%)

A. Stance phase:
1. Heel contact: Initial contact 2. Foot-flat: Loading response, initial contact of forefoot w. ground 3. Midstance: greater trochanter in alignment w. vertical bisector of foot 4. Heel-off: Terminal stance 5. Toe-off: Pre-swing

B. Swing phase:
1. Acceleration: Initial swing 2. Midswing: swinging limb overtakes the limb in stance 3. Deceleration: Terminal swing

Width of the base Body centre of gravity Knee flexion at stance Pelvic and trunk lateral shift Average length of the step Cadence Pelvic rotation

Walking Base or width base

Side-to-side distance between the line of the two feet Also known as stride width Shouldnt be more than 2 to 4 inches

Approx 15 inch average Dec may indicate pathology Always compare

Average cadence of approx 90 to 120 steps per minute Energy expenditure :only 100 calories

Center of Gravity (CG):

midway between the hips 2 inch in front of S2

Least energy consumption if CG travels in straight line Increased vertical motion may indicate pathology

CG

A. Vertical displacement:

Rhythmic up & down movement Highest point: midstance Lowest point: double support Average displacement: 5cm Path: extremely smooth sinusoidal curve

the knee should remain flexed in all components of stance(except heel strike)to prevent excessive vertical displacement of the centre of gravity. Eg. In push off when the ankle is in 20 deg planterflexion tends to cause the centre of gravity to rise , then the knee goes into 40 deg flexion to counterbalance Knee fused then this counterbalance is lost.

Knee flexion in stance phase:



Approx. 20o dip  Shortens the leg in the middle of stance phase  Reduces the height of the apex of the curve of CG

Lateral displacement:

Rhythmic side-to-side movement Average displacement:1inch Basically theres a 1inch shift to weight bearing side If gleuteus medius is weak,lateral shift is attenuated

Pelvic rotation: During swing phase pelvis rotated 4 deg forward, while the hip joint at opposite side acts as a fulcrum for rotation

Ankle mechanism:
Lengthens the leg at heel contact  Smoothens the curve of CG  Reduces the lowering of CG


(5) Foot mechanism:

Lengthens the leg at toe-off as ankle moves from dorsiflexion to plantarflexion  Smoothens the curve of CG  Reduces the lowering of CG


Most commonly affected by a pathology Pain any where affects it, with shortening of duration Shoe problems, nail sticking through shoe heel or bending, any loose object in shoe

FOOT:

heel spur, spike of bone protruding from medial tubercle on the planter surface of the os calcis sharp pain bursitis patient may hop onto the involved foot in attempt to avoid heel strike completely.

KNEE
normally extended. weak quadricep may use his hand knee unstable during heel strike.

FOOT:Dorsiflexors of foot(tib ant,ext dig longus and ext hallucis

longus) permits the foot to go into planterflexion through eccentric elongation so that foot flattens smoothly. Weak dorsiflexors or nonfunctioning they may slap foot at ground patients with fused ankle may not reach foot flat until midstance

FOOT: weight is borne evenly.

rigid pes planus and subtalar arthritis may develop pain when walking on uneven grounds those with fallen transerve arches may develop callosities over metatarsal head. corns may be painful

KNEE: quadricep contract to make knee stable, since its not normally straight.

Weakness may cause excessive flexion and instability. HIP:at this stage is 1inch lateral displacement to wt bearing side. weak gl medius makes pt lurch towards the involvedside to involve centre of gravity over hip. This is called abduction or gluteus medius lurch. Weak gl maximus may thrust thorax posteriorly to maintain hip extension. And

extensor or gluteus maximus lurch

FOOT: If having osteoarthritis or partial or fully fused metatarsophalangeal joint(hallux rigidus) he may be unwilling or unable to hyperextend the MTP joint of his great toe, and may be forced to push off from lateral side of his forefoot, a manoure which eventually causes pain. pain may be inc due to increase pressure at metatarsal head if callosities have been develop sec to dropped head--- metatarsalgia. Examine the shoe: instead of normal transeverse crease over the toe somewhat an oblique crease cutting across toes and forefoot may develop. KNEE: gastrocnemius soleus and flexor hallucis longus are vital to push off, weakness may result in a flat-footed or calcaneal gait

Fewer abnormalities evident

No longer subject to stress of wt bearing and support

FOOT: dorsiflexors of ankle are active during entire swing. They help shorten the extremity so it can clear ground by holding the ankle neutral. KNEE: reaches maximum degree of flexion b/n toe off and midswing, approx 65 degree. Serve to shorten to clear the ground HIP: quadricep begin to contract just before toe off to help initiate the forward swing of the leg. If the paitient has poor quadricep strength. He may rotate the pelvis anteriorly in an exagerated motion to provide forward thrust for the leg.

FOOT: when the ankle dorsiflexors are not working the toe of the shoe scapes the ground to produce a characteristic shoe scrape. To compensate the patient may flex his hip excessively to bend the knee, permitting the foot to clear the ground(steppage gait)

KNEE: the hamstring muscles contract to slow down the swing just prior to heel strike so that heel can strike ground quitely in ca controlled motion. if hamstring weak heel strike may be excesssively harsh causing thickening of the heel pad and the knee may hyperextend(back knee gait).

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3. The quadriceps femoris acts at the beginning of the stance phase extending the knee. The hamstrings flex the knee just before toe-off. 4. The dorsiflexors of the foot act immediately after heel strike to check plantar flexion under the force of gravity and bring the foot into full contact with the ground.
Deep or common fibular nerve deficit or L5 radiculopathy results in a foot slap gait due to inability to dorsiflex to slow plantarflexion.

5. The plantar flexors act throughout the second half of the stance phase powering the forward thrust of the body using the thigh and leg as a single unit. The body is powered forward by the plantar flexors and hip extensors. 6. As the body weight comes onto the foot the intrinsic foot muscles contract to support the plantar ligaments.

1. The hip flexors already functioning at the end of the stance phase continue into early swing phase along with the adductors and lateral rotators; however they are essentially silent in midswing relying on momentum of the thigh mass to bring the thigh forward. Thigh momentum is checked at the end of the swing phase by the hip extensors.

2. The hamstrings function late in the stance phase and continue into early swing phase to flex the knee. The forward momentum of the limb in the swing results in the transition from flexion to extension at the knee with some assistance from the quadriceps muscles. This momentum is checked by the hamstrings prior to heel strike. 3. Dorsiflexors and the ankle act throughout the swing phase.

Demonstration

Biomechanics of Gait Walking

At Ground Contact

Lateral Side

Medial Side

Contact Made on the Lateral Border of the Heel Foot is Supinated Foot is Rigid

Biomechanics of Gait Walking

Early Stance to MidStance

Lateral Side

Medial Side

Foot is Pronated Foot is Mobile (flexible) Enhances Balance

Biomechanics of Gait Walking

Late Stance to Toe-Off

Lateral Side

Medial Side

Foot is Supinated Foot is Rigid Enhances Propulsion

Biomechanics of Gait Walking

Pronation/Supination Issues: Too Little Loss of force dissipation Loss of Mobility Balance Stress Injury Too Much Relationship to Tibial Rotation Associated Patellar Tracking Issues Soft-Tissue Stress Control of Pronation/Supination Shoe Design Orthotics Muscle Strengthening Posterior Tib

Abnormalities in stance

Abnormalities in swing Pelvic rotation abnormalities

Stance phase decreases to remove weight off the effected side from wt bearing. Swing phase of normal foot shortened so it bear wt. Non-specific.

Contact at heel avoided. Because of pain hind foot is always elevated. So hoff off to forefoot.

Quadricep weakness doesnt allow extension so patient uses hand to do extension and lock knee by pressing at thigh.

Weakened foot and ankle dorsiflexors.

Patient with fixed planterflexion at ankle develop recurvatum at knee to accommodate forward motion of trunk and pelvis during midstance. Normally the knee during midstance is in slight flexion.

In midstance wt bearing side abducors contract to prevent excessive lifting of opposite side. In abductor lurch , patient lateral shift is >1 inch towards wt bearing side to decrease body energy expenditure.

At midstance ipsilateral hip must be maintained in extension or trunk will collapse forward. If gl maximus weak trunk goes posteriorly

Normal toe-off cant occur , whole foot is brought up from the ground . Seen in weakness of calf muscles and rigidity.

Weakness of foot and ankle dorsiflexors causes foot slap gait but is total paralysis of foot and ankle dorsiflexors then foot elevated with knee and hip compensating with flexion to elevate the foot.

Drop foot or stiff knee may elevate with help of hip elevation ipsilateraly. This is called hip hike gait.

Instead of hip hike another way will be to swing leg to outer side to make it off the floor.

Impaired balance and loss of coordination. This has high energy expenditure.

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