ASS{SSM{NT Of GAIT

Walking is the simple act of falling forward and catchingoneself. One foot is always in contact with the ground,and within a cycle, there are two periods of single-legsupport and two' periods of double-leg support. Withrunning, there is a period of time during which neitherfoot is in contact with the ground, a period called"double float."

Winter felt walking gait performs five main functions.1First, it helps to support of the head, arms, and trunk: bymaintaining a semirigid lower limb. Second, it helps tomaintain upright posture and balance. Third, it conu'olsthe foot to allow it to clear obstacles and enables gen-tle heel or toe landing through eccentric muscle action.FOurtll, it generates mechanical energy by concentricmuscle contraction to initiate, maintain, and, if desired,increase forward velocity. Finally, through eccentricaction of the muscles, it provides shock absorption andstability and decreases forward velocity of the body.

The locomotion pattern tends to be variable andirregular until about the age of 7 years.2 Several func-tional tasks are involved in gait, including forward pro-gression, which is executed in a stepping movement ina 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 repeatedadjustments of limb length. Finally, there is support ofthe 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 platformso 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 ofbook. This chapter gives only a brief overview of a com-plex task, assessment of normal and pathological gaidetailed assessment of gait is left to other authors.6-14Thvarious terms commonly used to describe gait, tlle nor-mal pattern of gait, the assessment of gait, and commoabnormal gaits are reviewed.

Definitions5-1o

Gait CycleThe gait cycle is the time interval or sequence of motiooccurring between two consecutive initial contacts of thesame foot (Figure 14-1). For example, if heel strike i.5the initial contact, the gait cycle for the right leg is froone heel strike to the next heel strike on the same f00-The gait cycle is a description of what happens in onleg. The same sequence of events is repeated with thother leg, but it is 1800 out of phase.8 Neumann clear!:-described the terminology that applies to the gait cycleevents1S(Figure 14-2). Table 14-1 demonstrates the peri-ods or phases of the gait cycle, the function of each phase...and what is happening in the opposite limb.8 The gait cy econsists of two phases for each foot: stance phase, willmakes up 60% to 65% of the walking cycle, and swingphase, 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 lengthor stride length decreases. For example, in jogging, thegait cycle is 70% of the walking cycle, and in running.

the gait cycle is 60% that of walking.16 In adclition, asthe speed of movement increases, the function of themuscles changes somewhat, and their electromyographicactivity may increase or decrease. Generally, gait velocitydecreases with age.17 Montero-Odasso et al. found thegait velocity «0.8 m/sec) could be used to determinemobility impairment in the elderly.18

The stance phase of gait occurs when the foot is on theoW1d and bearing weight (Figure 14-3). It allows thewer leg to support the weight of the body and, by sooing, acts as a shock absorber while allowing the body

-0 advance over the supporting limb.16 Normally, thishase makes up 60% of the gait cycle and consists of fivebphases, or instants.

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

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 initial contact instant is the weight-loadingor weight acceptance period of the stance leg, whichaccounts for the first 10% of the gait cycle. During thisperiod, one foot is coming off the floor while the other foois accepting body weight and absorbing the shock of initialcontact. Because both feet are in contact with the floor. i-is a period of double support or double-leg stance.

on the painful tissues. If the knee is weak, the patientmay extend the knee by using the hand or may hit theheel hard on the ground to whip the knee into exten-ion. A patient may do this because of weakness of the

muscles (e.g., reflex inhibition, poliomyelitis, an internalderangement of the knee, a nerve root lesion [L2, L3, orL4], femoral neuropathy). In the past, this instant wasreferred to as "heel strike"; however, with some path-ological gaits, heel strike may not be the first instant.Instead, the toes, the forefoot, or the entire foot mayinitially contact the ground. If the dorsiflexor muscles areweak, the foot drops, slaps, or flops down. The weaknessmay be caused by a peroneal neuropathy or nerve rootlesion (L4). A knee flexion contracture or spasticity maycause the same alteration.

Load Response (Weight Acceptance or Foot Flat)Load response is a critical event in that the person sub-consciously decides whether the limb is able to bear theweight of the body. The trunk is aligned with the stanceleg. The pelvis drops slightly on the swing leg side andmedially rotates on the same side. The flexed and later-ally rotated hip moves into extension, and the knee flexes15° to 25°. The tibia is medially rotated and begins tomove forward over the fixed foot as the body swings overthe foot. The ankle is plantar flexed, and the hindfoot isinverted. The foot moves into pronation, because thisposition unlocks the foot and enables it to adapt to dif-ferent terrains and postures. The forefoot is pronated,unlocking the subtalar and metatarsal joints to enablethem to absorb the shock more effectively, and the plan-tar aspect is in contact with the floor.

Abnormal responses include excessive or no kneemotion as a result of weak quadriceps, plantar flexor con-tractures, or spasticity.9

Midstance (Single-Leg Support)The midstance instant is a period of stationary foot sup-port. Normally, the weight of the foot is evenly distrib-uted over the entire foot. The trunk is aligned over thestance leg, and the pelvis shows a slight drop to the swingleg side.

During this stage, there is maximum extension of tilehip (lO° to 15°) with lateral rotation, and the greatestforce is on the hip. Painful hip, knee, or ankle conditionscause this phase to be shortened as the patient hurriesthrough the phase to decrease the pain. If the gluteusmedius (L5 nerve root) is weak, Trendelenburg's sign ispresent. The knee flexes, and the ankle is locked at 5° to8° of dorsiflexion, rolling forward on the forefoot (roll-off). The foot is in contact with tile floor; the forefoot ispronated, and the hindfoot is inverted. Tlus instant is acritical event for the ankle. If pain is elicited during thisperiod, the phase will be shortened and the heel may liftoff early. This pain is commonly caused by conditions

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

Terminal Stance (Heel Off)In the final stages, tile trunk is initially aligned overlower limbs and moves toward the stance leg. Thevis is initially level and posteriorly rotated and thento the swing leg side, remaining posteriorly rotated.heel is in neutral and slight medial rotation; the kneeextended with the tibia laterally rotated. At theplantar flexion occurs as the critical event. This ahelps to smooth the pathway of the center of gravit\.forefoot is initially in contact with the floor, andthe weight on the foot moves forward with plantarion so that only the big toe is in contact with the fiAt the same time, the forefoot moves from inversio -everSiOn.

Preswing (Toe Off)The preswing phase is the acceleration phase as the -pushes the leg forward. The trunk remains erect, thevis remains posteriorly rotated, and the lup is extenand slightly medially rotated. The knee flexes to ~-to 35° (critical event), and the ankle is plantar fieBecause 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 callSby a hallux rigidus, turf toe, or any otller patho =-involving tile great toe (hallux), especially the mesophalangeal joint of tile hallux. With injury to the j . -the patient is unable to push off on tile medial aspthe foot; instead, the patient pushes off on the laLaspect of the foot to compensate for the painful mesophalangeal joint or, in some cases, a painful metaarch resulting from increased pressure on the metaheads. If the plantar flexors are weak (e.g., SI-52 nerroot 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 decreaseload on the limb. Lyu and associates have shownusing a cane in the contralateral upper limb,36 if thetip touches the ground at the same time as the heelreduce the force at heel strike by 34%, by 25% atstance, and about 30% at toe off.

Swing PhaseThe swing phase of gait involves the lower limb inopen kinetic chain; tile foot is not fixed on the groand the stresses on tile limb are therefore less andto dissipate. During this phase, alterations occur fromspine down through the pelvis, hip, ankle, and foot. TI

Table 14-3Summary of Joint Motion and Forces during Swing Phase: Acceleration to Midswing and Midswing to Deceleration

Acceleration to Midswing Midswing to Deceleration

Joint Kinematic Motion Kinetic Motion Kinematic Motion Kinetic Motion

Hip Slight flexion (0° to Hip flexors working Continued flexion at Gluteus m:Lumus15°) moving to 30° concentrically to bring about 30° to 40° contracting eccentrically toflexion and lateral limb through; contralateral slow hip flexionrotation to neutral gluteus medius

concentrically contractingto maintain pelvis position

Knee 30° to 60° knee flexion Hamstrings concentrically Moving to near Quadriceps femorisand lateral rotation of contracting full extension and contracting concentricallytibia moving toward slight lateral tibial and hamstrings contractingneutral rotation eccentrically

Ankle and foot 20° dorsiflexion and Dorsiflexors contracting Ankle in neutral; Dorsiflexors contractingslight pronation concentrically foot in slight isometrically

supination

pelvis and hip provide the most stability in the lower limbduring the non-weight-bearing phase. Table 14-3 sum-marizes the motions occurring in the lower limb duringthe swing phase.

The three instants composing the swing phase of gaitare now described in order of occurrence.

Initial SwingDuring the first subphase of acceleration (Figure 14-11),flexion and medial rotation of the hip and flexion of theknee occur. The pelvis medially rotates and clips to theswing leg side. The trunk is aligned with the stance leg.In addition, the ankle continues to plantar flex. The footis not in contact with the floor. The forefoot continuessupinating, and the hindfoot continues everting. Thedorsiflexor muscles of the ankle contract to allow the footto clear the ground, and the knee exhibits its maximumflexion during gait of about 60°. If the quadriceps mus-cles are weak, the trunk muscles thrust the pelvis forwardo provide forward momentum to the leg.

MidswingDuring the midswing instant, the hip continues to flexand medially rotate, and the knee continues to flex. Theankle 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 adapto uneven terrain when it begins weight bearing. Theorefoot is supinated, and the hindfoot is everted. The

lvis and trunk are in the same position as during therevious stage. If the ankle dorsiflexor muscles are weak

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

Terminal Swing (Deceleration)During the final subphase, the hip continues to flex andmeclially rotate, and the knee reaches its maximum exten-sion. At the ankle, dorsiflexion has occurred. The forefoot issupinated, and the hindfoot is everted. The trunk and pelvismaintain the same position as before. The hamstring musclescontract during the terminal phase to slow the swing; if thehamstrings are weak (e.g., SI-S2 nerve root lesion), heelstrike may be excessively harsh to lock the knee in extension.

Although there is a tendency to talk about gait as actionaround joints, the examiner must not forget that musclesplay a significant role in what happens at the joints. Table14-4 illustrates the actions of some of the muscles usedduring gaitY

Hip. The function of the hip is to extend the leg dur-ing the stance phase and flex the leg during the swingphase. The ligaments of the hip help to stabilize it in exten-sion. The hip extensors help to initiate movement, as dothe hip flexors; both groups of muscles work phasically.The hip flexors (primarily the iliopsoas muscle) contr'ato slow extension; the hip extensors (primarily the ham-string muscles) contract to slow flexion. In this waywork eccentrically. The abductor muscles provide stabiliirrduring single-leg support, a critical event for the hip.

Weight Single Limb Swing LimbAcceptance Support Advancement

Reference le LR MSt TSt PSw ISw MSw TSwLimb

Opposite PSw PSw ISw/MSw TSw IC/LR MSt MSt TStLimb

5° 5° 5° 5° 5° 5°PELVIS Fwd Fwd 0° Bkwd Bkwd Bkwd 0° Fwd

Rotation Rotation Rotation Rotation Rotation Rotation

20°HIP 25° 25° 0° Apparent 0° 15° 25° 25°

Flex Flex Hyperext Flex Flex Flex

KNEE 0° 15° 0° 0° 40° 60° 25° 0°Flex Flex Flex Flex

100- 20° 10°ANKLE @o Plantar 5° 10° Plantar Plantar 0° 0°

Flex Dorsiflex Dorsiflex flex flex

30° MTP 60° MTPExt Ext

Figure 14-11ormal 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 ThePathokinesiology 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 14-4Muscle Actions during Gait Cycle

Phase of Gait Mechanical Goals Active Muscle Groups Examples

Stance PhaseInitial contact Position foot, begin deceleration Ankle dorsiflexors, hip extensors, Anterior tibialis, gluteus

knee flexors maximus, hamstringsLoading response Accept weight, stabilize pelvis, Knee extensors, hip abductors, Vasti, gluteus medius,

decelerate mass ankle plantar flexors gastrocnemius, soleusMidstance Stabilize knee, preserve momentum Ankle plantar flexors (isometric) Gastrocnemius, soleusTerminal stance Accelerate mass Ankle plantar flexors (concentric) Gastrocnemius, soleus

Swing PhasePreswillg Prepare for swing Hip flexors Iliopsoas, rectus femorisInitial swing Clear foot, vary cadence Ankle dorsiflexors, hip flexors Tibialis anterior, iliopsoas,

recms femorisMidswing Clear foot Ankle dorsiflexors Tibialis anteriorTerminal swing Decelerate shank, decelerate leg, Knee flexors, hip extensors, ankle Hamstrings, gluteus maximus,

position foot, prepare for contact dorsiflexors, knee extensors tibialis anterior, vasti

If there is loss of movement of the hip, the compensa-tory mechanisms are increased mobility of the knee onthe same side and increased mobility of the contralat-eral hip. In addition, the lumbar spine shows increasedmobility.

Knee. yvhen the knee is in flexion during the firstthree instants of the stance phase of gait, it acts as a shockabsorber. Painful knees are not able to do this. One ofthe critical events of the knee is extension. The functionsof the knee during gait are to bear weight, absorb shock,extend the stride length, and allow d1e foot to movethrough its swing. The quadriceps muscles use only 4%to 5% of their maximum voluntary contraction to extendthe knee, but in so doing, they help to control weightacceptance. The hamstring muscles flex the knee andlow the leg in the swing phase, working eccentrically.

If the knee has a flexion deformity, the hip is flexedand therefore loses its extension power, which is a criticalevent for the hip. Pathological conditions such as patel-lofemoral syndrome also cause deviations from normalgait. For exan1ple, patients with patellofemoral syndromehow less knee flexion during the single-leg stance phase,ombined with lateral femoral rotation during the swinghase.39 On heel strike to foot flat, the femur then medi-

ally rotates, and if this compensating medial rotation" too great, it causes excessive pronation, which thenstresses the medial aspect of the patellofemoral joint.

Gastrocnemius and Soleus. The gastrocnemius andsoleus muscles are important in gait. They use 85% oftheir 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 conservingenergy.'w To accomplish these functions during gait, thetriceps surae work eccentrically and concentrically.

Foot and Ankle. The foot and anlde play majorroles in gait in that the various joints allow the foot toaccommodate to the ground. The joints of the foot andankle work interdependendy during normal gait. Whenthe heel contacts the ground, the lower limb becomesa closed kinetic chain, and movements and stresses mustbe absorbed by the structures of the lower limb.

When looking at the ankle, d1e examiner shouldobserve immediate plantar flexion at initial contact. Lossof dus plantar flexion (e.g., tibial nerve neuropathy)results in an inability to transfer weight to the anteriorfoot, increased ankle dorsiflexion, and increased kneeflexion. In addition, the duration of single-leg stance onthe affected side decreases, and the step length on theopposite side decreases. Furthermore, quadriceps actionat d1e knee increases because of the lack of knee stabilitycaused by the loss of the triceps surae, with the end resultbeing that walking velocity decreases.4o The foot thendorsiflexes through midstance or single-leg stance, withmaximum dorsiflexion being reached just before heeloff. The examiner should note whed1er d1ere is sufficientplantar flexion during push-off.

The assessment of a patient's gait should be includeany assessment of the lower limb. The examiner ID

keep in mind that the posture of the head, neck, rhoand lumbar spine can affect gait even if no pathology --

evident in the lower limb. The examiner must be able toidentifY the action of each body segment and note anydeviation from normal during the individual phases ofgait. For this reason, it is important to understand thenormal parameters of gait and the mechanism of gait asit occurs. With this knowledge, the ways in which thegait is altered under pathological conditions can be bet-ter understood.

Musculoskeletal pathology tends to modifY gaitbecause of muscle weakness, pain, or altered ROM, sothe examiner should watch closely for these factors whenobserving gait. Many patients can adapt automatically tothese changes, provided they have normal sensation andcan develop selective controP Patients with upper motorneuron lesions have greater alterations and cannot easilyadapt because, in addition to the musculoskeletal prob-lems, they also present with spasticity, control problems,and sensory disturbances.9 It is important that the exam-iner read the patient's chart and take a history from thepatient regarding any disease or injury, past or present,that may be causing gait problems.

The examiner should first perform a general overviewof the patient's posture, looking for any asymmetry, andthen observe the patient's gait, looking at stride length,step frequency, time of s~g, speed of walking, and dura-tion of the complete walking cycle. This is normally donewith the patient in shorts, wearing no shoes or socks. Ifgait is observed wearing shoes, the same shoes shouldbe used for each testY A steady gait pattern is usuallyestablished within three steps; it is initiated by the body'sbecoming unbalanced so that the patient can lift one footoff the ground to take the first step.42After this overviewis completed, the examiner can look at specific parts ofthe gait in terms of phases and what happens at each jointduring these phases.

Because gait constantly changes as one stops and starts,hurries, dawdles, and walks with others, it is important toremember whether the movements the patient is capableof are normal and whether the speeds, phases, strides, anddurations of the cycles occur in normal combinations.In addition to observing walking at a normal speed, thepatient's slow and fast gait speeds should be examined tosee whether these changes affect the gait. The examinermust watch the upper limbs and trunk, as well as thelumbar spine, pelvis, hips, knees, feet, and ankles dur-ing these changes. Female patients should be in a braand briefs, and male patients should be in shorts. Thepatient should walk barefoot. In this way, the motionsof the toes, feet, legs, pelvis, trunk, and upper limbs canproperly be observed.

The examiner should ask the patient to walk in theusual 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 fronfrom behind, and from the side, in each instance obsen--ing from proximal to distal and watching the peh-and lumbar spine down to the ankle and foot as \ eas from the foot up. For example, in the swing phase(open kinetic chain) movement starts proximally anmoves distally. In the stance phase (closed kinetic chain _movement is reversed, starting in the foot and movin=proximally. The examiner should observe the moyc-ments in the trunk and upper limbs, which normally arin the opposite direction to those of the lower limThis method provides a sequential, thorough mannof assessment. Rancho Los Amigos Medical Center hasdeveloped a useful gait analysis chart (Figure 14-12By using the chart during observation, the examinerdetermine deviations and their effect on gait in an eas-ily used and easily retained method of recording. Thdark gray boxes indicate what normally should octhe lighter gray and white boxes indicate minor anmajor deviations from the normal, respectively. Mi.ndeviations imply that the functional task of walking'not affected. Major deviations imply that the mechaniof walking are affected adversely.43

Anterior ViewWhen observing from the front as tlle patient walks,examiner should note whether any lateral tilt of thevis occurs, whether there is any sideways swaying oftrunk, whether the pelvis rotates on a horizontal plane..whetller the trunk and upper extremity rotate inopposite direction to the pelvis, and whether recipro-cal arm swing is present. Usually, tlle trunk and uppcextremity rotation is approximately 1800 out of phasewith the pelvis-that is, as the pelvis and lower limrotate one way, the trunk and upper limb rotate inopposite direction. This action helps provide a balanc-ing effect and smoothes the forward progression of thbody. The examiner may also note movements at thhip (rotation and abduction-adduction), knee (rotatiand abduction-adduction), and ankle and foot (amoof 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 laterotation of the hips, femur, or tibia, and the position .-the feet as the patient goes through the gait cycle (Figure14-13). This view is best used to examine the weigh -loading period of the gait cycle. The examiner shoalso note whether there is any abduction or circumduc-tion of the swing leg, whether there is atrophy of thmusculature of the anterior thigh and leg, and wheth -the base width is normal.

GAIT ANALYSIS: FUll BODYRANCHO LOS AMIGOS MEDICAL CENTER

PHYSICAL THERAPY DEPARTMENT

Reference Limb:

LO RO

C- IE" ITrunk

Major De>iation

Minor Deviation

Lean: BIFLateral Lean: RlL

Rotates: BIF

Pelvis HikesTilt PIA

Lacks Forward RotationLacks Backward RotationExcess Forward Rotation

Excess Backward RotationIpsilateral Drop

Contralateral Drop

Hip Flexion: limitedExcess

Inadequate ExtensionPast Retract

Rotation: IRIERAdl Abduction: Adl Ab

Knee Flexion: LimitedExcess

Inadequate ExtensionWobbles

HyperextendsExtension Thrust

VarusNalgus: VrlVlExcess Contralateral Flex

Ankle Forefoot ContactFoot-Flat Contact

Foot SlapExcess Plantar Flexion

Excess DorsiflexionInversion/Eversion: fvlEv

Heel Off

No Heel OffDrag

Contralateral Vaulting

Toes UpInadequate Extensj~n

Clawed

WeightAccept

le LR

Single LimbSupport

MSt TStMAJORPROBLEMS:

WeightAcceptance

Single LimbSupport

Swing LimbAdvancement

Excessive DEWeight Bearing

SwingLirnbAdvancement

Figure 14-12Gait 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 ViewFrom the side, the examiner should observe rotation ofthe shoulder and thorax during the gait cycle, as wellas reciprocal arm swing. Spinal posture (e.g., lordo-sis), pelvic rotation, and movements in the joints of thelower limbs should be noted. These movements includeflexion-extension at the hip, flexion-extension at the

knee, and dorsiflexion-plantar flexion at the ankle. Fromthe lateral aspect, the examiner may also observelength, 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 walkingand the various body parts.

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

The examiner must remember that there may be somecompensation by the lumbar spine for limitation of move-ment in the hip. The patient should be observed to deter-mine whether there is sufficient knee extension at initialcontact, followed almost immediately by slight flexionuntil the foot makes contact with the floor; whether thereis control of the slightly flexed knee during load responseand midstance; and whether there is sufficient flexion dur-ing preswing and initial swing. Also, any hyperextensionof tlle knee during the gait cycle should be noted. Finally,the examiner should note whetller there is coordinationof movement among the hip, knee, and ankle; even oruneven gait length; and even or uneven duration of steps.

As the patient moves from initial contact to loadingresponse, the foot flexes immediately, and the knee flexesuntil the foot is flat on the floor. During this period, thehip is also flexed. During midstance, the ankle dorsiflexesas the body pivots in an arc over the stationary foot. At thesame 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 andknee 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 legprogresses to midswing, the ankle dorsiflexes, and the hipand knee begin to extend. As the patient moves from mid-swing to terminal swing, the ankle remains in the neutralposition while the hip and knee continue extending. Asthe leg moves from terminal swing to initial contact, theknee reaches maximum extension; the ankle remains inneutral, and no furtller hip extension occurs at this stage.

Posterior ViewWhen observing the gait cycle fi-om behind, the examinershould notice the same structures that were viewed fromthe front. Rotation of the shoulders and thorax, recipro-cal arm swing, and pelvic list and rotation may be noted

posteriorly, as well as hip, knee, ankle, and subtalar jo· -movement. Heel rise and base of support (base wiare easier to view posteriorly. Any abnormal abductioadduction movements or lateral displacement of thesegments should be noted. This view is best to exthe weight-unloading period of the gait cycle. The exiner can note whether heel rise is equal for both feet ~whether the heels turn in or out. The observation halso include lateral movement of the spine and the mlature of the back, buttocks, posterior thigh, and calf

FootwearThe patient should be asked to walk in normal fi -.wear as well as in bare feet. The examiner shouldtime to observe the patient's footwear and observewearing down of the heels or socks, the condition ofshoe uppers, creases, and so on. The feet shouldbe examined for callus formations, blisters, corns, an-bunions. Different shoes can modify a patient's gait an-the 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 verti10ading.44

Most gait assessment involves observation. However, rhexaminer should take time, especially if he or she notiealtered gait, to measure muscle strength (active and resistemovement) and range of movement (active and passi,-emovement) 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 differencbetween the left and right gait cycles.4s,46 Leg lengthdiscrepancies (see Chapter 11 for leg length measure-ment) may also affect gait. Children tend to have bettecompensation mechanisms for leg length discrepancithan do adults.47 Table 9-7 gives functional causes of leglength differences. Tables 11-10, 12-2, and 13-2 outlinemal alignments that may also affect gait.

Locomotion ScoresIn addition to the detailed assessment of gait, locomo-tion scales or grading systems have been developed thatinclude subjective and objective scores, which are com-bined for a total score. Figure 14-14 is a locomotion scor-ing 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 tofalling.49-S1 In addition to including all aspects oflocomo-tion, it gives an overall estimation of functional disabilityfor patients with rheumatoid arthritis. Wolf and associatesreported on the Emory Functional Ambulation Profileand established its reliability and validity.s2,53The profile

Detailed and Total Locomotion Score in Chronic ArthritisUPPER EXTREMITIES

A. Subjective score (max. 100 points)

Pain (max. 33 points)33 None at ordinary activity2S Mild, inconstant, unilaterally, not interfering with normal

activity17 Mild bilateral or moderate unilateral, constant use of anal-

gesics10 Moderate pain despite large doses of analgesics, affecting

activitySevere pain despite large doses of analgesics. affecting activ-ity

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:_

19-20. Wash the axillas sO 20 00 R 190 0 o L 20

21-22. Reach things over sO 20 00 R 21shoulder level 0 0 o L 22

23-24. Use of walking sup- 120 70 40 00 R 23port(s) 0 0 0 o L 24Sum: right _ left_ Both (R/2 + L/2)_

ABILITY (max. 67 points)Degree of disability

Severeor

General (max. 20 points) None Mild Moderate unableS-6. Manage work, 80 60 3D . ORs

household routines, 0 0 0 OD L 6shopping. childcare (min. 3 of 4)

7-8. ADL (home and 70 sO 20 00 R 7kitchen chore, per- 0 0 0 o L8sonal care, dressing,etc.)

9-10. Drive a car or use sO 20 00 R 9public transporta- 0 0 o L 10tion

Special (max. 47 points)11-12. Feeding (hold knife, 100 70 40 00 R 11

cup, open milk 0 0 0 o L 12pack)

13-14. Carry 3 kg burden -0 20 00 R 13~O 0 OL14

lS-18. Use telephone sO 20 00 R lS0 0 o L 16

17-18. Comb hair, brush sO 20 00 R 17teeth. shave 0 0 o L 18

Right LeftShoulder (max. 35 points)2S-26. Flexion: >90· ; lOp, 4S-90· ; S p, 02S 026

<4S· ; Op27-28. Extension: >20· ; Sp, 0-20· ; 3p, 027 028

O' ; Op29-30. Abduction: >90· ; lap, 4S-90· ; Sp, 029 030

<4S· ; Op31-32. Medial rot.: >lS· ; Sp, <lS· ; Op 031 03233-34. Lateral rot.: >10· ; Sp, <10· ; Op 033 034

Elbow (max. 35 points)3S-36. Flexion (from 90·): >120· ; lOp, 100-120· ; o3S 036

7p, 90-100· ; 4p, O' ; Op37-38. Extension defect: 0-30· = lOp, 30-60· ; 7p, 037 038

60-90' ; 4p, 90· ; Op39-40. Deformity: none + stable ; Sp, rigid deformity 039 040

= 2p. laxid = Op41-42. Varus-valgus: <So = lOp, S-10· ; 7p 041 042

stressed varus-valgus >lS· ; 3p, >2S' ; Op

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; Sp, 045 046severe; Op

Sum: right _ left _ Both (R/2 + L/2)_

OBJECTIVESCORE: _ SUBJ. + OBJ. SCORE: 0 (a)(upper extremities)

Figure 14-14Locomotion 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 patientsand can differentiate between those suffering from a strokeand normals. The profile does time trials and measuressuch things as a 5-meter (16.4 feet) walk on bare floorand carpeted floor, an "up and go" task, negotiatingan obstacle course, and stair climbing. Other fi.mctionaltests include the Get Up and Go Test,54 the FunctionalAmbulatory Classification Scale,55,56and the PerformanceOriented Balance and Mobility Assessment (POMA)Y

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

tain an energy-saving gait. The patient tries to use themost energy-saving gait possible.58 Speed of walking canalso modify many of the normal parameters of gait.59

Therefore, not only the gait pattern but also the speedof the activity and its effects must be noted. This type ofassessment allows the examiner to set appropriate goalsand plan a logical approach to treatment.

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

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

47. Pain (max. 44 points)44 None at ordinary activity40 Slight, occasional ache or awareness of pain, not influencing

activity30 Mild bilateral or moderate unilateral, may take analgesics20 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 bedridden48-50. Pain score reduction

- 25% Moderate or severe pain from more than one ipsilateraljoint

- 50% Moderate or severe pain from more than one contralat-eral joint

-10% Severe pain from upper extremities or neck

Walk (max. 36 points)51. Limp: none = 12p, slight = 8p, moderate = 0

5p, severe =Opnone = 12p, cane for long walks = Bp,cane most of time = 5pone crutch or can't use = 3p, two 0canes = 2ptwo crutches or can't walk = Opunlimited = 12p, >400m = 8p, 0<400m = 5pindoors only = 2p, bed or chair = Op

without difficulty = 6P 0with difficulty or by using banister =3pwith great difficulty or unable = Opwithout difficulty = 6p, with diffi- 0culty = 3p, unable = Opwithout difficulty = 6p, only short 0time or on high cbair = 3p, unable touse any chair = Op

can use public transportation = 2p,unable = Op

D. Objective score-physical signs (max. 100 points)Right Left

Hip (max. 35 points)58-59. Flexion: >90· = lOp, 60--90· = 5p, 058 059

<60· = Op60-61. Extension defect: 0-10· = lOp, 10-30· = 5p, 060 061

>30· '= Op62-63. Abduction/adduc- >10· = lOp, -10-10· = 062 063

lion: 5p, <-10· = Op64-65. Rotation: >0· = 5p, O·= Op 064 065

Knee (max. 35 points)66-67. Flexion: >100· = lOp, 80--100· = 066 06i

8p, 60--80· = 5p68-69. Extension defect: 00 = lOp, 0-100 = 8p, 10-

200 = 5p20-30· = 2p, >30· = Op 068 069

70-71. Varus-valgus: <70 = lOp, 7-150 = 8pstressed v/v 15-300 = 5p, 070 071>30· = Op

72-73. Deformity: none + stable = 5p, rigid 072 073= 2p, laxid = Op

Ankle (max. 15 points)74-75. Deformity (rigid, laxid): none = l5p, mild =

lOp, moderate = 5p, severe = Op

Feet (max. 15 points)76-77. Deformity (rigid, laxid): None = l5p, mild =

lOp, moderate = 5p, severe = OpSUM: right: _ left: _ Both (R/2 + U2):_

OBJECfIVE SCORE:_ SUBJ. + OBJ. SCORE: 0 (b)(lower extremities)

side. Finally, they may occur as compensations for injuryor pathology on the opposite or contralaterallinlb (Table14-6).15 Some of the more common gait abnormalities arediscussed next, but this list is by no means inclusive.

The antalgic or painful gait is self-protective and is theresult of injury to the pelvis, hip, knee, ankle, or foot.The stance phase on the affected leg is shorter than thaton the nonaffected leg, because the patient attempts toremove weight from the affected leg as quickly as possi-ble; therefore, the amount of time on each leg should benoted. 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 Inaddition, the painful region is often supported by one

hand, if it is within reach, and the other arm, acting asa counterbalance, is outstretched. If a painful hip is caus-ing the problem, the patient also shifts the body weightover the painful hip. This shift decreases the pull of theabductor muscles, which decreases the pressure on thefemoral head from more than two times the body weightto approximately body weight, owing to vertical insteadof angular placement of the load over the hip. Flynn andWidmann have outlined some of the causes of a painfullinlp in children60 (Table 14-7).

The arthrogenic gait results from stiffuess, laxity, or defor-mity, and it may be painful or pain free. If the knee orhip is fused or the knee has recently been removed froma cylinder cast, the pelvis must be elevated by exaggerated

Text continued on page 964

1. VARIABILITY - A MEASURE OF INCONSISTENCY AND ARRHYTHMICITY OF STEPPING AND OF ARM MOVEMENTS

o = fluid and predictably paced limb movements1 = occasional interruptions (changes in velocity), approximately 25% of time2 = unpredictability of rhythm approximately 25%-75% of time3 = random timing of limb movements

2. GUARDEDNESS - HESITANCY, SLOWNESS, DIMINISHED PROPULSION, AND LACK OF COMMITMENT INSTEPPING AND ARM SWING

o = good forward momentum and lack of apprehension in propulsion1 = center of gravity of head, arms, and trunk (HAT) projects only slightly in front of push-off, but still good arm-leg

coordination2 = HAT held over anterior aspect of foot, and some moderate loss of smooth reciprocation3 = HAT held over rear aspect of stance-phase foot, and great tentativity in stepping

3. STAGGERING - SUDDEN AND UNEXPECTED LATERALLY DIRECTED PARTIAL LOSSES OF BALANCE

o = no losses of balance to side1 = a single lurch to side2 = two lurches to side3 = three or more lurches to side

4. FOOT CONTACT - THE DEGREE TO WHICH THE HEEL STRIKES THE GROUND BEFORE THE FOREFOOT

o = very obvious angle of impact of heel on ground1 = barely visible contact of heel before forefoot2 = entire foot lands flat on ground3 = 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= obvious angulation of thigh backward during double support (10 degrees)1 = just barely visible angulation backward from vertical2 = thigh in line with vertical projection from ground3 = thigh angled forward from vertical at maximum posterior excursion

6. SHOULDER EXTENSION - A MEASURE OF THE DECREASE OF SHOULDER ROM

0= clearly seen movement of upper arm anterior (15 degrees) and posterior (20 degrees) to vertical axis of trunk1 = shoulder flexes slightly anterior to vertical axis2 = shoulder comes only to vertical axis, or slightly posterior to it during flexion3 = shoulder stays well behind vertical axis during entire excursion

7. ARM-HEEL STRIKE SYNCHRONY - THE EXTENT TO WHICH THE CONTRALATERAL MOVEMENTS OF AN ARM ANDLEG ARE OUT OF PHASE

0= good temporal conjunction of arm and contralateral leg at apex of shoulder and hip excursions all of the time1 = arm and leg slightly out of phase 25% of the time2 = arm and leg moderately out of phase 25%-50% of the time3 = little or no temporal coherence of arm and leg

Figure 14-15~lodified Gait Abnormality Rating Scale (GARS-M). (From Dutton M: Orthopedic examination, C1Jaluation,md intervention, p. 389, New York, 2004, McGraw-Hill.)

Initial Load Heel Opposite Toe Feet Tibia Next iEVENTS contact response off initial contact off adjacent vertical con

PERIODS Loading Mid stance r Terminal Pre I Initial I Mid swing I Terminalresponse stance swing swin§ swing

TASKS Wei§ht Single-limb support Limb advancementIacceptance

PHASES Stance pli1ase I Swin§ phase

".CYCLE Right gait cycle

Figure 14-2Terminology to describe the events of the gait cycle. Initial contact corresponds to the beginning of stancewhen the foot first contacts the ground at 0% of gait cycle. Load response occurs when the contralateral footleaves the ground at 10% of gait cycle. Heel offcorresponds to the heel lifting from the ground and occurs atapproximately 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. Feetadjacent 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 gaitcycle. The final event is, again, initial contact, which in fact is the start of the next gait cycle. These eightevents 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 theheel 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 thetime 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 acceptance-when 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 stancephase 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

Unloading and preparing forswing (preswing)

SwingSupport of entire body weight:center of mass moving forward

Unloading and preparing for swing(preswing)

Foot clearanceLimb advances in front of bodyLimb deceleration, preparation forweight transfer

Single limb supportSingle limb supportSingle limb support

Initial swing~lidswingTerminal swing

62-7575-8585-100

From Sutherland DH et aI: Kinematics of normal hwnan walking. In Rose J, Gamble ]G, editors: Human locomotion,27 Baltimore, 1994, Williams & Wilkins.

Table 14-5Gait Deviations Secondary to Specific Impairments*

Gait Deviations at the Hip/Pelvis/Trunk Secondary to Specific Hip/Pelvis/Trunk Impairments *

Observed Gait Deviation at the Hip/ Selected Pathological Mechanical Rationale and/or AssociatedPelvis/Trunk Likely Impairment Precursors Compensations

Lateral trunk lean toward the stance leg; becausethis movement compensates for a weakness, itis often called a "compensated" Trendelenburggait and is referred to as a waddling gait ifbilateral

Excessive downward drop of the conu"alateralpelvis during stance (referred to as a positiveTrendelenburg sign if present during single-limbstanding)

Forward bending of the trunk during mid andterminal stance, as the l~p' is moved over the foot

Trunk lurches b..ackwa[dand toward theunaffected stance leg from heel off to mid swing

Posterior tilt of the pelvis during initial swing

Hi,P circun~duction: semicircle movement of thehip during swing-combining hip flexion, hipabduction, and forward rotation of the pelvis

This action moves the line of gravity of the trunkbehind the hip and reduces the need for hipextension torque

Shifting the trunk over the supporting limbreduces the demand on the hip abductors

Shifting the trunk over the supporting lowerextremity reduces compressive joint forcesassociated with the action of hip abductors

Whereas the Trendelenburg sign may beobserved in single-limb standing, a compensatedTrendelenburg gait often occurs when there hasbeen severe weakness of the hip abductors

Forward u'unk lean is llsed to compensate forlack of hip extension; an alternate adaptationcould be excessive lumbar lordosis

Keeping the hip at 30 degrees of flexionminimizesintraarticular pressure

Lack of hip extension in terminal stance iscompensated for by increased lordosis

Hip flexion is passively generated by a backwardmovement of the trunk

Abdominals are used during initial swing toadvance the swing leg

Hip abductors are used as flexors

Gait Deviations at the Knee Secondary to Specific Knee Impairments*

Selected Pathological Mechanical Rationale and/or AssociatedLikely Impail'ment Precursors Compensations

Rapid extension of the knee (knee extensorthrust) immedjately after initial contact

Marked weakness of the hipabductors

Hip pain

Mild weakness of the gluteusmedius of the stance leg

Depending on the status of the posteriorstructures of the knee, may occur with orwithout knee hyperextension

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

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

Knee extensor weakness (seethe two previously describedgait deviations)

La.,'Cityof dle posterior andlateralligamentous jointsU'uctmes of the knee

Knee flexion contractme > 10°(genu flexum)

Hamstring overactivity(spasticity)

Knee pain and joint effusion

Spasticity of knee extensorsKnee extension contractme

Femoral nerve palsy, L3- L4compression neuropathy

Traumatic injury or progressivelaxity

Knee remains fully extended throughout stance.An associated anterior trunk lean in dle early partof stance moves the line of gravity of the trw1k,slightly antelior to me axis of rotation of meImee, which keeps me lmee extended wimoutaction of tlle knee extensors; d1isgait deviationmay lead to an excessivestretching of theposterior capsule of me knee and eventual kneehyperextension (genu recurvatwn) during stance

Knee is kept in extension to reduce the need forquadriceps activity and associated compressiveforces; it may be accompanied by an antalgicgait pattern characterized by a reduced stancetime and shorter step lengm

Secondary to progressive stretching of theposterior capsule of the knee

Rapid varus deviation of the knee duringmid stance, typically accompanied by kneehyperextension

Associated increase in hip flexion and ankledorsiflexion dming stance

Knee is kept in flexion since this is me positionof lowest inu'aarticular pressure

Compensatory hip hiking and/or hipcircumduction could be noted

Upper motor neuron lesionImmobilization (cast, brace) orsmgical fusion

Gait Deviations at the Ankle/Foot Secondary to Specific Ankle/Foot Impairments*

"Foot slap": rapid ankle plantar flexion occursfollowing heel contact; the name foot slap isderived from the characteristic noise made by meforefoot hitting me ground

Entire plantar aspect of me foot touches theground at initial contact,! followed by normal,passive anlde dorsiflexion dming the rest ofstance

Initial contact with me ground is made by meforefoot followed by the heel region; normalp:lssiv' ankl' dorsiflexion occurs during stance

Mild weakness of ankledorsi flexors

Marked weakness of ankledorsi flexors

Severe weakness of anldedorsi flexors

Selected PathologicalPrecursors

Common peroneal nervepalsy and distal peripheralneuropathy

ConU110nperoneal nervepalsy and distal peripheralneuropathy

Common peroneal nervepalsy and distal peripheralneuropathy

Mechanical Rationale and/or AssociatedCompensations

Ankle dorsiflexors have sufficient strengtllto dorsiflex me anlde during swing but notenough to control anlde plantar flexion afterheel contact

Sufficient strength of the dorsiflexors to partially,but not completely, dorsiflex tlle anlde duringswing; normal dorsiflexion occurs during stanceas long as the ankle has normal range of motion

No active ankle dorsiflexion is possible duringswing; 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 theheel never makes contact with the ground duringstance

Initial contact is made with the forefoot, and theheel is brought to the ground by a posteriordisplacement of the tibia

Heel remains in contact with the ground late interminal stance

Supinated foot position and weight bearing onthe lateral aspect of the foot during stance

Excessive foot pronation occurs during stancewith failure of the foot to supinate in mid stance;normal medial longitudinal arch noted duringswing

Excessive foot pronation with weight bearing onthe medial portion of the foot during stance; themedial longitudinal arch remains absent duringswing

Excessive inversion and plantar flexion of thefoot and ankle occur during swing and at initialcontact

Ankle remains plantar flexed during swing and canbe associated with dragging of the toes, typicallycalled drop foot

Likely Impairment

Heel pain

Plantar flexion contracture(pes equinus deformity) orspasticity of ankle plantarflexors

Plantar flexion contracture(pes equinus deformity) orspasticity of ankle plantarflexors

Weakness or flaccid paralysisof plantar flexors with orwithout a fixed dorsiflexedposition of the ankle (pescalcaneus deformity)

Pes cavus deformity

Rearfoot varus and/orforefoot varus

Weakness (paralysis) of ankleinvertors

Pes planus deformity

Pes equinovarus becauseof spasticity of the plantarflexors and invertors

Weakness of dorsiflexors and/or pes equinus deformity

Selected PathologicalPrecursors

Calcaneal fracture, plantarfasciitis

Upper motor neuron lesion/cerebral palsy, cerebrovascularaccident (CVA)

Upper motor neuron lesion(cerebral palsy, CVA)

Ankle fusion in a plantar flexedposition

Congenital or acquired musculartightness of ankle plantarflexors

Peripheral or central nervoussystem clisorders

Excessive surgical lengthening ofthe Achilles tendon

Congenital or acquiredstructural deformity

Upper motor neuron lesion(cerebral palsy, CVA)

Mechanical Rationale and/or AssociatedCompensations

Purposeful strategy to avoid weight bearing onthe heel

To maintain the weight over the foot, the kneeand hip are kept in flexion throughout stance,leading to a "crouched gait"

Knee hyperextension occurs during stance owingto the inability of the tibia to move forwardover the foot; hip flexion and excessive forwardtrunk lean during terminal stance occur to shiftthe weight of the body over the foot

Characteristic bouncing gait pattern

Excessive ankle dorsiflexion results in prolongedheel contact, reduced push off, and a shorterstep length

A high mediallongituclinal arch is noted withreduced midfoot mobility throughout swingand stance

Excessive foot pronation and associatedflattening of the medial longitudinal arch maybe accompanied by a general internal rotationof the lower extremity during stance

An overall excessive internal rotation of the lowerextremity during stance is possible

Contact with the ground is made with the lateralborder of the forefoot

Weight bearing on the lateral border of the footduring stance

Hip hiking, hip circumduction, or excessive hipand knee flexion of the swing leg or vaulting ofthe stance leg may be noted to lift the toes offthe ground and prevent the toes from draggingduring swing

From Ncumnnl1 DA: [(ill1'.rilllWJY l~rtlJc III1IJClIllI.rkvlctal Sj'stC1Jl:.finmrlnlill1/s o('fJliy. iCIII 1'1'IIIIIIili"";IIII, pp (1 M, . (,(,, SI• 11 1111'" 11111'111I ,I III '" 'Ill ,11'11"111111111' 111'"" '"'"1'1\ .11, I' 1'111111111,,\.11 '" 1"1/""111 11 Ill" 1111' "I 11111.111111111111111 1110 11 .11.1111 1111 1 1 .. 111 •. 1 '''"111 •• ,.11 ,,11 III lit 11 "1,10,,, 11 I 1 I I. iI I 11 I

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

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

Observed Gait Deviation at theHipjPelvis/Trunk

Forward bending of the trunk duringthe loading response

Forward bending of the trunk duringmid and terminal stance

Excessive hip and knee flexion duringswing

Hip hiking (elevation of the ipsilateralpelvis during swing)

Excessive backward horizontalrotation of the pelvis on the side ofthe stance leg in terminal stance

Often caused by the lack of ankledorsiflexion of the swing leg; may also becaused by a functionally or anatomicallyshort contralateral stance leg

Lack of shortening of the swing legsecondary to reduced hip flexion,reduced knee flexion, and/or lack ofankle dorsiflexion

Lack of shortening of the swing legsecondary to reduced hip flexion,reduced knee flexion, and/or lack ofankle dorsiflexion

Functionally or anatomically short stance legAnkle plantar flexor weakness

Trunk is brought forward to move the lineof gravity anterior to the a.,xisof rotationof the knee, thereby reducing the needfor knee extensors

Lack of ankle dorsiflexion during stanceresults in knee hyperextension andforward trunk lean to move the weight ofthe body over the stance foot

Used to clear the toes of the swing leg

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

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

Ankle plantar flexor weakness leads toprolonged heel contact and lack ofpush off; an increased pelvic horizontalrotation is used to lengthen the limb andmaintain adequate step length

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

Observed Gait Deviation at theKnee

Knee is kept in flexion during stancedespite the knee having normalrange of motion on examination

Hyperextension of the knee (genurecurvarum) from initial contact topre swing

Antalgic gait

Impairments at the ankle or the hipincluding a pes calcaneus deformity,plantar flexor weakness, and hip flexioncontracture

Ankle plantar flexion contracture (pesequinus deformity) or spasticity of ankleplantar flexors

Painful stance leg

Lack of ankle dorsiflexion of the swing legor a short stance leg

Exaggerated ankle dorsiflexion or hipflexion during stance forces the knee in aflexed position; the contralateral (healthy)swing leg shows exaggerated hip and kneeflexion to clear the toes owing to thefunctionally shorter stance leg

Knee must hyperextend to compensate forthe lack of forward displacement of thetibia during stance

This is characterized by a shorter steplength and stance time on the side ofthe painful lower extremity; it may beaccompanied by ipsilateral trunk lean; ifhip pain, contralateral trunk lean occurswith knee and foot pain

Strategy to increase toe clearance of theswing leg and is typically accompanied byincreased 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 theAnklejFoot

Vaulting: compensatory mechanismdemonstrated by exaggerated ankleplantar flexion during mid stance;leads to excessivevertical movementof the body

Excessivefoot angle during stancethat is called toeing-out

Reduction of the normal foot ankleduring stance that is called toeing-in

Any impairment of the contralateral lowerextremity that reduces hip flexion, kneeflexion, or ankle dorsiflexion duringswing

Retroversion of the neck of the femur ortight hip external rotators

Excessivefemoral anteversion or spasticityof the hip adductors and/or hip internalrotators

Strategy used to allow the foot of afunctionally long, contralateral lowerextremity to clear the ground duringswing

Foot is in excessivetoeing-out because ofexcessiveexternal rotation of the lowerextremity

General internal rotation of the lowerextremity

Table 14-7Differential Diagnosis of Antalgic Gait

Toddler's fracture (tibia or foot)Osteomyelitis, septic arthritis, discitisArthritis (juvenile rheumatoidarthritis, Lyme disease)

Discoid lateral meniscusForeign body in the footBenign or malignant turnor

Fracture (especiallyphyseal)Osteomyelitis, septic arthritis, discitisLegg-Calvt-Perthes diseaseTransient synovitisOsteochondritis dissecans (knee or ankle)Discoid lateral meniscusSever's apophysitis (calcaneus)Accessory tarsal navicularForeign body in the footArthritis (juvenile rheumatoid arthritis,Lyme disease)

Benign or malignant tumor

Stress fracture (femur, tibia, foot, parsinterarticularis)

Osteomyelitis, septic arthritis, discitisSlipped capital femoral epiphysisOsgood-ScWatter disease or Sinding-Larsen-Johansson syndrome

Osteochondritis dissecans (knee or ankle)Chondromalacia patellaeArthritis (Lyme disease, gonococcal)Accessory tarsal navicularTarsal coalitionBenign or malignant turnor

© 2001 AmericanAcademyof OrthopaedicSurgeons.ReprintedfromtheJournal of the American Academy of Orthopaedic Surgeons, vot9(2),pp 89-98.

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

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

base (Figure 14-17). The gait of a person with cerebellarataxia includes a lurch or stagger, and all movements areexaggerated. The feet of an individual with sensory ataxiaslap the ground because they cannot be felt. The patienalso watches the feet while walking. The resulting gait·irregular, jerky, and weaving.

Joints of the lower limb may exhibit contracture ifimmo-bilization has been prolonged or pathology to the joinhas not been properly cared for. Hip flexion contractureoften results in increased lumbar lordosis and extensionof the trunk combined with knee flexion to get the foo

I

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

on the ground. With a lmee £lexion contracture, thepatient demonstrates exc~ssive ankle _dorsiflexion fromlate s ·ng..p.ha..s..c~oearly stance phill'e on !he ul1involvedleg and earl heel rise on the ·l1Y.Qlve.d-.sllkin_terminalstance. Plantar flexiQn contracture at the ankle results inknee hyperextension (midstance of affected leg) ans! for-ward bending of the trunk with hi flexion (midstance toterminal stance of affected leg). Heel rise on the affectedleg also occurs earlier. 33

This childhood gait is seen with talipes equinovarus (clubfoot) (Table 14-8). Weight bearing is primarily on the dor-solateral or lateral edge of the foot, depending on the degreeof deformity. The weight-bearing phase on the affected limbis decreased, and a limp is present. The pelvis and femur arelaterally rotated to partially compensate for tibial and footmedial rotation.2

Figure 14-17Ataxic 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 primaryextensor, is weak, the patient thrusts the thorax posteriat initial contact (heel strike) to maintain hip extensiothe stance leg. The resulting gait involves a characre - -backward lurch of the trunk (Figure 14-18).

Table 14-8Differential Diagnosis of a Nonantalgic limp

Equinus Gait (Toe-Walking)Circumduction Gait/Vaulting Gait

Idiopathic tight Achilles tendonClubfoot (residual or untreated)Cerebral palsyLimb-length discrepancy

Limb-length discrepancyCerebral palsyAny cause of ankle or knee

stiffness

Cerebral palsyMyelodysplasiaCharcot- Marie- Toothdisease

Friedreich's ata.xiaTibial nerve palsy

Legg-Calve- Perthes diseaseDevelopmental dysplasia of the hipSlipped capital femoral epiphysisMuscular dystrophyHemiplegic cerebral palsyWeak gluteus medius

© 2001 American Academy of Orthopaedic Surgeons. Reprinted from the Journal of the American Academy of Orthopaedic Surgeons, vol 9(2),pp 89-98.

Gluteus Medius (Trendelenburg's) GaitIf the hip abductor muscles (gluteus medius and mini-mus) are weak, the stabilizing effect of these musclesduring stance phase is lost, and the patient exhibits anexcessive lateral list in which the thor:Lx is thrust lat-erally 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 theipsilateral hip abductors do not stabilize or prevent thedroop). If there is bilateral weakness of the gluteus mediusmuscles, the gait shows accentuated side-to-side move-ment, resulting in a wobbling gait or "chorus girl swing. ~This gait may also be seen in patients with congenital dis-location of the hip and coxa vara (see Table 14-8).

Rgure 14-18Gluteus maximus gait.

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

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

The neck, trunk, and knees of a patient with parkinsoniangait are flexed. The gait is characterized by shuffling orshort rapid steps (marche a petits pas) at times. The armsare held stiffly and do not have their normal associativemovement (Figure 14-21). During the gait, the patientmay lean forward and walk progressively faster as thoughunable to stop (festination).61

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

Figure 14-21Parkinsonian 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.terstep length on the unaffe~ted side.33

The psoatic limp is seen in patients with conditions affect-ing the hip, such as Legg-Calve- Perthes disease. Thepatient demonstrates a difficulty in swing-through, andthe limp may be accompanied by exaggerated trunk andpelvic movement.33 The limp may be caused by weaknessor reflex inhibition of the psoas major muscle. Classicmanifestations of this limp are lateral rotation, flexion,and adduction of the hip (Figure 14-22). The patientexaggerates movement of the pelvis and trunk to helpmove the thigh into flexion.

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

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

Figure 14-23Scissors gait. (Redrawn from Judge RD, Zuidema GD, FitzgeraldFT: Clinical diagnosis: a pbysiological approach, p. 439, Boston, 19 .:Litde, Brown.)

Figure 14-22Psoatic limp. Note lateral rotation, flex.ion, and abduction of affectedhip.

band. If the trunk, hip flexors, and ankle muscles cannotperform this movement, the patient may use a hand toextend the knee.33

This gait is the result of spastic paralysis of the hip adduc-tor muscles, which causes the knees to be drawn togetherso that the legs can be sWlmg forward only with greateffort (Figure 14-23). This is seen in spastic paraplegicsand may be referred to as a neurogenic or spastic gait.

If one leg is shorter than the other or there is a deformityin one of the bones of the leg, the pa.tiencmay demon-strate a lateral shift to the affected side, and the elvistilts down on the affected side, creatin ~ limp (Figure14-24). The patient may also supinate the foot on theaffected side to try to "lengthen" the limb. The joints ofthe unaffected limb may demonstrate exaggerated flex-ion, or hip hiking may occur during the swing phase toallow the foot to clear the ground.33 The weight-bearingperiod may be the same for the two legs. How a patient

Figure 14-24Short leg gai t.

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

The patient with a steppage gait has weak or paralyzeddorsiflexor muscles, resulting in a drop foot. To compen-sate and avoid dragging the toes against the ground, thepatientlifts the knee higher than normal (Figure 14- 25).At initial contact, the foot slaps on the ground becauseof loss of control of the dorsiflexor muscles resultingfrom injury to the muscles, their peripheral nervesupply, or the nerve roots supplying the muscles (seeTable 14-8).64

Table 14-9 lists common gait pathologies that can mod-ifYgait and the phase in which the deviation occurS.35

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

Table 14-9Common Gait Pathologies

Phase

Midstance through toe off Compensated forefoot or rearfoot varusdeformity; uncompensated forefoot valgusdeformity; pes planus; decreased ankledorsiflexion; increased tibial varum; longlimb; uncompensated medial rotation oftibia or femur; weak tibialis posterior

Compensated forefoot valgus deformity;pes cavus; short limb, LU1compensatedlateral rotation of tibia or femur; limitedcalcaneal eversion; plantar flexed first ray;upper motor neuron muscle balance

Excessive tibia vara; forefoot varus; tibialisposterior weakness; excessive lowerextremity medial rotation (because ofmuscle imbalances, femoral anteversion)

Contracture; overactiviry of muscles onmedial aspect of foot

Weak invertors; foot hypermobiliryHeel cord contracture; increased tone 0-

gastrocnemius and soleus

Excessive valgusBouncing or exaggerated plantarflexion

Heel strike to toe offMidstance through toe off

Initialcontact

Terminalstance

The load response and midstance instants consist ofthe single support or single-leg stance, which accountsfor the next 40% of the gait cycle. During tIlis period,one leg alone carries the body weight while the otherleg goes through its swing phase. The stance leg must beable to hold the weight of the body, and the body mustbe able to balance on the one leg. In addition, lateral hipstability must be exhibited to maintain balance, and thetibia of the stance leg must advance over the stationaryfoot.

The terminal stance and preswing instants makeup the weight-unloading period, which accOlmts forthe next 10% of the gait cycle. During tIlls period, thestance leg is unloading the body weight to the contra-lateral 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.

The swing phase of gait occurs when the foot is not bear-ing weight and is moving forward (Figure 14-4). Theswing phase allows the toes of the swing leg to clear thefloor and allows for leg length adjustments. In addition,it allows the swing leg to advance forward. It makes upapproximately 40% of the gait cycle and consists of threeubphases.

,,,,\\II

\I

\I

\ I\ '\ I, \~ ..-.._--,I ",,"'~,_.- .•...•..

Initial swing(acceleration)

Terminal swing(deceleration)

Igure 14-4wing phase of gait.

Figure 14-3Stance phase of gait.

Subphases (Instants) of Swing Phase

• Initial swing (acceleration)• Midswing• Terminal swing (deceleration)

Acceleration occurs when the foot is lifted off thefloor. During normal gait, rapid knee flexion and ankledorsiflexion occur to allO\,vthe swing limb to accelerateforward. In some padl010gical conditions, loss or altera-tion of knee flexion and ankle dorsiflexion leads to altera-tions in gait.

The midswing instant occurs when the swing leg isadjacent to the weight-bearing leg, which is in midstance.

During the final instant (terminal swing or decel-eration), the swinging leg slows down in preparationfor initial contact with the floor. With normal gait,active quadriceps and hamstring muscle actions arerequired. The quadriceps muscles control knee exten-sion, and the hamstrings control the amount of hipflexion.

During running or with increased velocity, the stancephase decreases and a float phase or double unsup-ported phase occurs while the double support phasedisappears (Figure 14_5).16,19 Although the single-legstance phase decreases, the load increases two or threetimes.20 The motion occurring at each of the joints(pelvis, hip, knee, ankle) is similar for walking and forrunning, but the required range of motion (ROM)increases widl the speed of the activity. For examplehip flexion in walking is about 40° to 45 0, whereas inrurming it is 60° to 75°.21

Double-leg stance is that phase of gait in which parts ofboth feet are on the grOlmd. In normal gait, it occurstwice during the gait cycle and represents about 2-of 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 andknee flexion to clear foot)

Excessive knee flexion

Excessive knee extension/inadequateknee flexion

Genu recurvatum (kneehyperextension)

Abnormal internal hip rotation(toe-in gait)

Abnormal external hip rotation (toe-out gait)

Decreased hip swing through (psoaticlimp)

Excessive medial or lateral femurrotation (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; pescalcaneus deformity

Gastrocnemius and soleus weakness;Achilles tendon rupture; metatarsalgia;hallux rigidus

Dorsiflexor weakness; lack oflower limbsensation

Dorsiflexor weakness or paralysis; functiona..leg length discrepancy

Hamstring contracture; decreased range 0':-

motion in ankle dorsiflexion; plantar flexmuscle weakness; lengthened limb; hipflexion contracture

Pain; anterior trunk deviation/bending;weakness of quadriceps, hyperextension isa compensation and places body weightvector anterior to knee; spasticity ofthe quadriceps, noted more during theloading response and during initial swingintervals; joint deformity

Quadriceps femoris weak or short;compensated hamstring weakness; Achilltendon contracture; habit

Adaptive shortening of iliotibial band;weakness of hip external rotators; femoralanteversion; adaptive shortening of hipinternal rotators

Adaptive shortening of hip externalrotators; femoral retroversion; weakness ofhip internal rotators

Spasticity or contracture of ipsilateralhip adductors; ipsilateral hip adductorweakness; coxa vara

Legg-Calve-Perthes disease; weakness orreflex inhibition of psoas major muscle;pain

Medial or lateral hamstrings tight,respectively; opposite muscle groupweakness; anteversion or retroversion,respectively

Abductor muscle contracture; instability;genu valgum; leg length discrepancy; fearoflosing balance

Adductor muscle contracture; genu varum

Increased limb length; abductor muscleshortening or overuse; stiff hip or knee

Increased limb length; hamstring weakness:inadequate hip or knee flexion or ankledorsiflexion; quadratus lumborumshortening

Vaulting (ground clearance of swinging Foot flat to toe offleg will increase if subject goes up ontoes of stance period leg)

Inadequate hip flexion Acceleration through heel strike

Inadequate hip extension (causes trunk Midstance through toe offfonvard bending, increased lordosis)

Excessive trunk back bending (gluteus Heel strike through midstancemaximus gait)

Excessive trunk forward bending Deceleration through midstance

Excessive trunk lateral flexion Foot flat through heel off(compensated Trendelenburg's gait)

Pelvic drop Foot flat through heel off

lower cadence than expected forperson's agehorter stance phase on involvedside and decreased swing phase onuninvolved side (shorter stride lengthon uninvolved side, decrease lateralsway over involved stance linlb,decrease in cadence, decrease invelocity, use of assistive device)tance phase longer on one side

Functional leg-length discrepancy; vaultingoccurs on shorter limb side

Hip flexor muscle weakness; hip extensormuscle shortening; increased limb length-hip joint arthrosis

Hip flexion contracUlre; hip extensormuscle weakness; iliotibial bandcontracture; hip flexor spasticity; pain

Inability to extend hip; hip flexioncontracUlre or hip ankylosis

Hip extensor or flexor muscle weakness; hippain; decreased range of motion of knee

Quadriceps femoris and gluteus maxim usweakness; decreased ankle dorsiflexion; hipflexion contracture

Gluteus medius weakness; hip pain; unequalleg length; hip pathology; wide base

Contralateral gluteus medius weakness;adaptive shortening of quadraUlslumborum; contralateral hip adductorspasticity

Adaptively shortened/spasticity of hipflexors on same side; limited hip jointflexion

Generalized weakness; pain; joint motionrestrictions; poor volwltary motor control

Antalgic gait resulting from painful injuryto lower limb and pelvic region

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

dapted from GiaUonardo LM: Gait. In Myers RS, editor: Sat~nders manual of physical thet·apy practice, p 1112, Philadelphia, 1995, WEaunders; and Dutton M: CJt.·thopedicexamination, evaluation and intervention, New York, 2004, McGraw-Hill.

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

0 10 20 30 40 50 60 70 80 90 100

II I

, I I I I' I I II: : : IStance (65%) Swing (35%)

I I , IRight heel Mid Foot Left heel

strike stance off strikeI , , ,I , , ,, , , ,I i I i I I I, , 1 , , , II , , Double Left , Double 1

Right heel Mid Toe limb heel Mid limb Right heelstrike stance off un- strike stance un- strike

I , ,supported

, , supported II I I , , II I I

, , , I ,

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

Right heel Left Left heel Right Right heel Leftinitial contact pre-swing initial contact pre-swing initial contact pre-swing

I I I , , II , I , , ,, , I , , ,, , I , I ,

Right single Left singlesupport support

, , I , , ,, , I , , ,, I I , , I

0% 15% 45% 60% 100% rIII

Right stance phase (60%) Right swing phase (40%) III

0% 40% 55% 85% 100%

Left swing phase (40%) Left stance phase (60%)

Time, percent of cycle

Figure 14-6TIme dimensions of the walking cycle. (Adapted from Inman VT, fullston HT, Todd F: Human walking, p. 26,Baltimore, 1981, Williams & Wilkins.)

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

The parameters that follow and their values are con-sidered normal for a population between the ages of 8and 45 years. It should be pointed out, however, thata relatively normal gait pattern is seen in persons asyoung as 3 years of age.2 There are, however, differencesbetween individuals of the same sex and between menand women.23 For the majority of the population outsideof these ages, there are alterations caused by neurologi-cal development, balance control, aging, changes in limblength, and maturation.2 For example, with maturity,walking velocity and step length increase, and cadencedecreases.24 It is also important to evaluate gait on thebasis of normal gait for someone the same age. This isespecially true for children.

Gait Parameters That are Significantly Decreasedin 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 normal base width, which is the distance betweenthe two feet, is 5 to 10cm (2 to 4 inches; Figure 14-7).If the base iswider, the examiner may suspect some pathol-ogy (e.g., cerebellar or inner ear problems) that resultsin poor balance, a condition such as diabetes or periph-eral neuropathy that may indicate a loss of sensation, or

Figure 14-7Normal base width.

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

Step length, or gait length, is the distance benveen suc-cessive contact points on opposite feet (see Figure 14-1).

ormally, this distance is about 72 cm (28 inches) beingrelatively constant for each individual (i.e., step lengthis commonly related to preferred walking speed)IS,26andshould be equal for both legs. It varies with age and sex,with children taking smaller steps than adults and femalestaking smaller steps than males.20 Height also has aneffect: a taller person takes larger steps. Step length tendsto decrease with age, fatigue, pain, and disease. If steplength is normal for both legs, the rhythm of walkingwill be smooth. If there is pain in one limb, the patientattempts to take weight off that limb as quickly as pos-sible, altering the rhythm.

Normal Gait Parameters

• Base width:• Step length:• Stride length:• Cadence:• Gait speed:

5-10cmapproximately 72 cmapproximately 144 cm90-120 steps/minapproximately 1.4 m/sec

Stride length is the linear distance in the plane of pro-gression between successive points of foot-to-floor con-tact of the same foot. The stride length is normally about144 cm (56 inches) and in reality is one gait cycle. ISStridelength, like step length, decreases with age, pain, disease,and fatigue.17,27 The age changes are often the result ofdecreased walking pace or speed.27,28

Lateral pelvic shift, or pelvic list, is the side-to-sidemovement of the pelvis during walking. It is necessaryto center the weight of the body over the stance leg forbalance (Figure 14-8). The lateral pelvic shift is normally2.5 to Scm (1 to 2 inches). It increases if the feet arefurther apart. The pelvic list causes relative adduction of

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

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

Vertical pelvic shift keeps the center of gravity frommoving up and down more than S cm (2 inches) dur-ing normal gait. By means of a vertical pelvic shift, thehigh point occurs during midstance and the low poinduring initial contact; the height of these points mayincrease during the swing phase if the knee is fused ordoes not bend because of protective spasm or swelling.The head is never higher during normal gait than it iwhen the person is standing on both feet. Thereforeif a person can stand in an opening, he or she shouldbe able to move through the opening without hittingthe head.7 On the swing phase, the hip is lower on theswing side, and the patient must flex the knee and dor-siflex the foot to clear the toe. This action shortens theextremity length at midstance and decreases the centerof gravity rise.

gure 14-9civic 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 cen-

of 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 concur-nt 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 theount of rotation. For example, rotation in the tibia isee times greater than rotation in the pelvis?

_·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 womencause men tend to have a greater body mass in theulder area. The vertical and horizontal displacements

of the center of gravity describe a figure eight, occupy-ing a 5-cm (2-inch) square within the pelvis during walk-ing. The vertical clisplacement, which describes a smoothsinusoidal curve during walking, can be observed fromthe side. The patient's head descends during weight-loading and weight-unloading periods and rises duringsingle-leg stance.

The normal cadence is between 90 and 120 steps permi.nute.29.31 The cadence of women is usually 6 to 9 stepsper minute higher tl1an that of men.31 Witl1 age, thecadence decreases. Figure 14-10 illustrates tl1e cadenceof normal gait from heel strike to toe off showing thechanging weight clistribution. With pathology or defor-mity (e.g., a cavus foot), this weight-bearing pattern maybe altered. As the pace of walking increases, the stridewidtl1 increases, and the toeing-out angle decreases. Gaitspeed is about lAm/sec (3mph)J5

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

Stance PhaseAs previously mentioned, there are five instants involvedduring the stance phase of gait. These are now describedin order of occurrence. This phase is tl1e closed kineticchain phase of gait. The action occurring at the vari-ous joints causes a chain reaction because of the stressesput on the joints and supporting structures with weightbearing. The foot becomes the fixed stable segment, andalterations occur from the foot up, with the joints of thefoot adapting first, followed by those of the ankle, knee,hip, pelvis, spine, and finally the upper limb, which actsas 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 theground. Normally, tl1is occurs when the heel strikes andtl1e limb is being prepared to take weight. During theinitial contact, the pelvis is level and medially rotated onthe side of initial contact, whereas the trunk is alignedbetween the two lower limbs. The hip is flexed 30° to49° 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. Atthis instant, tl1ere is little force going through the limb,

If pain occurs in the heel at this time, it may be caby a heel spur, bone bruise, heel fat-pad bruise orsitis. This pain may cause increased fIexion of thewith early plantar flexion to relieve the stress or pn::ss:~

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

Table 14-2Summary of Joint Motions at the Hip, Knee, Tibia, Foot, and Ankle during the Stance Phase of Gait

Hip

Kinetic Motion

Internal Forces

20° to 40° of hip flexion movingtoward extension; slightadduction and lateral rotation

Hip moving into extension,adduction, medial rotation

Reaction force in front of joint;flexion moment moving towardextension; forward pelvicrotation

Moving through neutral position;pelvis rotating posteriorly

10° to 15° extension of hipabduction, lateral rotation

Moving toward 10° extension,abduction, lateral rotation

Reaction force posterior to hipjoint; extension moment

Extension moment decreasingafter double-limb supportbegins

Decrease of extension moment

Gluteus maximus and hamstringsworking eccentrically to resistflexion moment; erector spinaeworking eccentrically to resistforward bend

Gluteus maximus and hamstringscontracting concentrically tobring hip into extension; erectorspinae resisting trunk flexion

Iliopsoas working eccentrically toresist extension; gluteus mediuscontracting in reverse action tostabilize opposite pelvis

Iliopsoas activity continuing

Adductor magnus workingeccentrically to control orstabilize pelvis; iliopsoas activitycontinuing

Kinematic Motion Kinetic Motion

Phase Knee Tibia External Forces Internal Forces

Heel strike In full extension Slight lateral Rapidly increasing Quadriceps femoris contractingbefore heel contact; rotation reaction forces behind eccentrically to control rapidflexing as heel strikes knee joint causing knee flexion and to preventfloor flexion moment buckling

Foot flat In 20° flexion moving Medial rotation Flexion moment After foot is flat, quadricepstoward extension femoris activity becoming

concentric to bring femurover tibia

Midstance In 15° flexion moving Neutral Maximum flexion Quadriceps femoris activitytoward extension moment decreasing; gastrocnemius

working eccentrically tocontrol excessive kneeextension

Heel off In 4° flexion moving Lateral rotation Reaction forces moving Gastrocnemius beginning totoward extension anterior to joint; work concentrically to start

extension moment knee flexionToe off Moving from near Lateral rotation Reaction forces moving Quadriceps femoris contracting

full extension to 40° posterior to joint as eccentricallyflexion knee flexes; flexion

moment

Kinematic Motion Kinetic Motion

Phase Foot Ankle External Forces Internal Forces

Heel strike Supination (rigid) at Moving into plantar Reaction forces behind Dorsiflexors (tibialis anterior,heel contact flexion joint axis; plantar extensor digitorum longus,

flexion moment at and extensor hallucis longus)heel strike contracting eccentrically to

slow plantar flexionFoot flat Pronation, adapting to Plantar flexion to Maximum plantar Dorsiflexion activity decreasing;

support surface dorsiflexion over a flexion moment; tibialis posterior, flexor hallucisfixed foot reaction forces longus, and flexor digitorum

beginning to shift longus working eccentrically toanterior, producing control pronationa dorsiflexion moment

Midstance Neutral 3° of dorsiflexion Slight dorsiflexion Plantar flexor musclesmoment (gastrocsoleus and peroneal

muscles), activated to controldorsiflexion of the tibiaand fibula over a fixed foot,contracting eccentrically

Heel off Supination as foot 15 ° dorsiflexion Maximal dorsiflexion Plantar flexor muscles beginningbecomes rigid for toward plantar moment to contract concentrically topush-off flexion prepare for push off

Toe off Supination 20° plantar flexion Dorsiflexion moment Plantar flexor muscles at peakactivity but becoming inactiveas foot leaves ground

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