Gait

basics of Gait normal & abnormal with images for a PG students in a simplest & short way

1. GAIT DR. SHANTILAL SANKHLA ORTHO PG GGSMCH FARIDKOT

2. The ‘ gait ’ may be defined as the forward propulsion of body by the lower limbs in a systematic, coordinated semi-rotatory movements of the trunk, arm and head. A normal gait must be rhythmic and soundless, having springiness in the feet which work alternatively in a definite cyclic order.

3. The basic unit of measurement in gait analysis is the gait cycle. a normal gait cycle is divisible into two phases for each extremity: The stance phase, and The swing phase.

4. Subdivision of phases

5. COMPARISON OF GAIT TERMINOLOGY Traditional pattern – Heel strike Foot flat Mid-stance Heel off Toe off Acceleration Mid-swing Deceleration Rancho Los Angious (RLA) - Initial contact Loading response Mid-stance Terminal stance Pre-swing Initial swing Mid-swing Terminal swing

6. STANCE PHASE Heel strike phase : Begins with initial contact & ends with foot flat It is beginning of the stance phase when the heel contacts the ground. Foot flat: It occurs immediately following heel strike It is the point at which the foot fully contacts the floor. Mid stance: It is the point at which the body passes directly over the supporting extremity

7. Heel off: the point following midstance at which time the heel of the reference extremity leaves the ground. Toe off: The point following heel off when only the toe of the reference extremity is in contact with the ground.

8. SWING PHASE Acceleration phase: It begins once the toe leaves the ground & continues until mid-swing, or the point at which the swinging extremity is directly under the body. Mid-swing: It occurs approx. when the extremity passes directly beneath the body, or from the end of acceleration to the beginning of deceleration. Deceleration: It occurs after mid-swing when limb is decelerating in preparation for heel strike.

9. RLA PHASES OF GAIT Initial contact It refer to the initial contact of the foot of leading lower limb. Normally the heel pointed first to contact. In abnormal gait it is possible to either whole foot or toes rather than the heel to strike. Load response Begins at initial contact & ends when the contra lateral extremity lifts off the ground at the end of the double-support phase. It occupies about 11% of gait Mid-stance phase (RLA) Begins when the contra-lateral extremity lifts off the ground at about 11% of the gait cycle Ends when the body is directly over the supporting limb at about 30% of the gait cycle.

10. Terminal stance (RLA) Begins when the body is directly over the supporting limb at about 30% of the gait cycle Ends just before initial contact of the contra-lateral extremity at about 50% of the gait cycle. Pre-Swing (RLA) It is the last 10% of stance phase and begins with initial contact of the contra-lateral foot (at 50% of the gait cycle) and ends with toe-off (at 60%). Initial swing (RLA) Begins when the toe leaves the ground & continues until max knee flexion occurs. Mid-Swing (RLA) Encompasses the period from maximum knee flexion until the tibia is in a vertical position. Terminal swing (RLA) Includes the period from the point at which the tibia is in the vertical position to a point just before initial contact.

11. In normal walking the foot placed on the ground in an angle taken from the centre of heel to second toe- ‘ toe out ’ or ‘ foot angle ’ and it is on an average 7degree. The distance between the heel strike of one lower limb to the heel strike of the other lower limb is denoted as “ step length ’’. The distance between the heel strike of one lower limb to the next heel strike of the same lower limb is denoted as “ stride length ”. The time taken for completion of heel strike of one lower limb to the next heel strike of same lower limb ( i.e. completion of one gait cycle) is denoted as “ stride duration ”.

12. In normal walking Linear distance between the mid points of the two feet varies from 5 to 10 cm and is known as “ width of base support ”. “ Cadence ” is the number of steps taken per minute which varies on several factors mainly the step length, speed of walking, sex, body built, obesity, surface on which walking is done, etc. Stance time : It is the amount of time that elapses during the stance phase of one extremity in a gait cycle. Single-support time : It is the amount of time that elapses during the period when only one extremity is on the supporting surface in a gait cycle.

13. Double-support time: During normal gait, for a moment, the two lower extremities are in simultaneous contact with the ground. This happen between push-off and toe-off on one side and between heal strike and foot flat on the contralateral side. During this period, both legs support the body weight, and this is known as “ double support ”. The period of this double support is inversely proportional to the cadence of the gait.

14. ABNORMAL (ATYPICAL) GAIT

15. There are numerous causes of abnormal gait. There can be great variation depending upon the severity of the problem. If a muscle is weak, how weak is it? If joint motion is limited, how limited is it? In ‘ limping ’ the patient avoids weight bearing on the affected side as far as possible (diminished stance phase). Limping denotes a painful condition on the affected side. In lurch , the patient prolongs the stance phase to improve the stability . Lurching denotes variable failure of abduction mechanism.

16. Abnormality in gait may be caused by Pain Joint muscle range-of-motion (ROM) limitation Muscular weakness/paralysis Neurological involvement (UMNL/ LMNL) Leg length discrepancy

17. Types of abnormal gait Due to pain – Antalgic or limping gait – ( Psoatic Gait ) Due to neurological disturbance – Muscular paralysis – both Spastic ( Circumduction Gait, Scissoring Gait, Dragging or Paralytic Gait, Robotic Gait [Quadriplegic]) and Flaccid ( Lurching Gait, Waddling Gait, Gluteus Maximus Gait, Quadriceps Gait, Foot Drop or Stepping Gait, ) Cerebellar dysfunction ( Ataxic Gait ) Loss of kinesthetics sensation ( Stamping Gait ) Basal ganglia dysfunction ( Festinating Gait )

18. Due to abnormal deformities – Equinus gait Equino-varous gait Calcaneal gait Knock & bow knee gait Genu-recurvatum gait Due to Leg Length Discrepancy (LLD) – Equinus gait

19. ANTALGIC GAIT-PAINFUL GAIT: Due to pain anywhere from foot to hip, the patient avoids bearing weight on the affected limb. Reduced stance phase, shortened step length, shortened stride length, shortened reciprocal arm swing, increased velocity of steps.

20. SCISSORING GAIT One leg crosses directly over the other with each step like crossing the blades of a scissor. It results from spasticity of bilateral adductor muscle of hip. Example: cerebral diplegia

21. IN –TOEING GAIT It usually results due to metatarsus adductus , tibial bowing with tibial torsion or persistent femoral anteversion. Usually resolves by 8 years of age.

22. OUT-TOEING GAIT The normal range for out-toeing is from 0 to 30*. In most infants/toddlers this out-toeing resolves spontaneously. When it associated with lateral tibial torsion, it can become worse with growth and may need surgical correction.

23. HIGH STEPPING (STEPPAGE) OR FOOT-DROP GAIT; EQUINUS GAIT During the heel strike attempt, the toes drop on the ground first (due to foot drop). To avoid this and to clear the ground, the patient flexes the hip and knee excessively, raises the foot and slap it on the floor forcibly. In few cases the patient starts walking with dragging the toes on the ground without making any attempt to flex the hip and the knee and raise the foot to clear the ground- dragging gait.

24. TOE WALKING GAIT By the age of 3 years heel strike pattern of gait must be established. If toe walking is persisting beyond 3 years, it s/b taken as abnormal and pathology s/b searched/investigated for. Usual causes of persistent ( beyond 3 year) toe-walking are: Cerebral palsy- spastic diplegia Muscular dystrophies Residual polio deformities Post burn contractures Post infective ( in calf muscles / regions) contracture Spinal cord tumours Idiopathic- it is the most common.

25. SPASTIC GAIT (HEMIPLEGIC GAIT OR CIRCUMDUCTION GAIT) Here the spastic muscles do not allow the hip and knee to be flexed enough for the foot to clear the ground. So the person rotates the hip sideways during the swing phase and places the foot in flattened manner or places the toes first before heel strike.

26. Gradually due to contracture of the planter flexures, heel strike can not be possible. On the affected side, the upper limb is usually flexed.

27. HELICOPOD GAIT A gait in which legs and feet are thrown in half circles as in hemiplegia.

28. LATHYRIATIC GAIT In lathyriasis there is a combination of spasticity, hyperabduction and dragging of lower limb elements in gait

29. WADDLING GAIT OR DUCK GAIT When there is disturbance in the abduction mechanism of the hip, there is increased lordosis. While walking the body sways from side to side on a wide base. Therefore, the patient lurches on both sides while walking like a duck. Examples: In b/l congenital dislocation of hip Osteomalacia Pregnancy Myopathy Paralysis of abductors of hips

30. TRENDELENBURG’S GAIT It may be U/L or B/L. B/L Trendelenburg’s Gait is almost like the waddling gait. When unilateral patient lurches on the affected side and the pelvis drops on the opposite side of hip. Examples: CDH, fracture of femoral neck, polio paralysis.

31. DRUNKERS OR REELING GAIT Here the patient tends to walk irregularly on a wide base, swinging sideways without stability and balance with tendency of falling with each step ( seen in cerebellar incoordination, or in drunken states).

32. FESTINANT GAIT OR FESTINATING GAIT OR SHORT SHUFFLING GAIT Due to rigidity of muscles the patient adopts the stooping posture (flexed neck, trunk, hip & knee), in which the centre of gravity falls anteriorly. Here the patient, with stooping body, is propelled forward quickly in successions as if trying to catch up with the centre of gravity. Examples : parkinsonism, Wilson’s disease, cerebral atherosclerosis.

33. STAMPING GAIT Occurs in sensory ataxia, e.g. tabes dorsalis, syringomyelia, DM, leprosy. The patient raises his feet abnormally high and jerk them forward to strike the ground slowly with a stamp due to lack of kinesthetics. It look like space walk.

34. KNOCK KNEE GAIT While walking, the patient flexes the hips slightly, the knee points appose each other, and the ankle and feet are kept apart with tendency of toe-in.

35. GENU RECURVATUM GAIT In paralysis of the hamstring muscles (e.g. in polio) the knee goes in hyperextension while transmitting weight in the midstance phase.

36. CALCANEAL GAIT Result from paralysis plantar flexors causing dorsiflexor contracture. The patient will be walking on his heel (heel walking) It is characterized by greater amounts of ankle dorsiflexion & knee flexion during stance & a shorter step length on the affected side. Single-limb support duration is shortened because of the difficulty of stabilizing the tibia & the knee

37. QUADRICEPS GAIT Quadriceps action is needed during heel strike & foot flat when there is a flexion movement acting at the knee. Quadriceps weakness/ paralysis will lead to buckling of the knee during gait & thus loss of balance. Patient can compensate this if he has normal hip extensor & plantar flexors. Compensation: With quadriceps weakness, the individual may lean forward over the quadriceps at the early part of stance phase, as weight is being shifted on to the stance leg. Normally, the line of force falls behind the knee, requiring quadriceps action to keep the knee from buckling. By leaning forward at the hip, the COG is shifted forward & the line of force now falls in front of the knee. This will force the knee backward into extension.

38. Another compensatory manoeuvre to use is the hip extensors & ankle plantar flexors in a closed chain action to pull the knee into extension at heel strike (initial contact). In addition, the person may physically push on the anterior thigh during stance phase, holding the knee in extension.

39. GLUTEUS MEDIUS GAIT is more or less as Trendelenburg’s gait.

40. GLUTEUS MAXIMUS GAIT The gluteus maximus act as a restraint for forward progression. The trunk quickly shifts posteriorly at heel strike (initial contact). This will shift the body's COG posteriorly over the gluteus maximus, moving the line of force posterior to the hip joints. With foot in contact with floor, this requires less muscle strength to maintain the hip in extension during stance phase. This shifting is referred to as a “ Rocking Horse Gait ” because of the extreme backward-forward movement of the trunk.

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