pathological_gait_gibbs.pdf hasan khan presentation

Biomechanical gait

1. A

Y A

DUNDEE

The Institute of Motion Analysis & Research

Pathological Gait

Sheila Gibbs
Senior Clinical Gait Analyst

The Institute of Motion Analysis &
Research

2. A

Y 4

DUNDEE

Institute of Motion Analysis & Research

A normal abnormal??
Is this possible??

www.dundee.ac.uk/orthopaedics/Imar2003

3. ERs,
Institute of Motion Analysis & Research

¡Y 4

© DUNDEE

If you don’t understand the
problem you shouldn’t be trying to
fix it!

James Robb
Consultant Orthopaedic Surgeon, Royal Hospital for Sick Children, Edinburgh

www.dundee.ac.uk/orthopaedics/Imar2003

5. „SERSIT,
8 br Institute of Motion Analysis & Research

\
rez Description of the Deviation

¢ Identify.
— The joint or segment involved.
— The timing of the problem e.g. Stance or swing.
— The plane and direction involved e.g. Sagittal plane

flexion.
— The type of abnormality e.g. | Range of motion.

www.dundee.ac.uk/orthopaedics/Imar2003

6. Institute of Motion Analysis & Research

NERSIT;
$ a,

1
€. Description of the Deviation

Drop foot gait:
— Joint/segment = Supination of the fore-foot
— Timing = seen throughout swing phase
and at initial contact but
corrects by mid-stance
— Plane = combined sagittal and coronal
= flaccid paralysis of the Peroneii

— Type

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7. „SERSIT,
8 br Institute of Motion Analysis & Research

\

rez Description of the Deviation

Gage [1991] has suggested 5 attributes for
normal gait:

— Stance phase stability

— Swing phase clearance

— Adequate foot pre-positioning

— Adequate step length

— Energy conservation

www.dundee.ac.uk/orthopaedics/Imar2003

8. „SERSIT,
6 Institute of Motion Analysis & Research

! \
“uv Description of the Deviation
Sagittal Plane:

Initial Loading Mid- Late- Initial Mid- Late-
contact response stance stance swing swing swing

Pelvis

Hip

Knee

Ankle

Hind-

foot

Fore-

foot

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9. eo Tro.

Y 4

DUNDEE

Institute of Motion Analysis & Research

Functional Loss

The structural system
The motor system
The sensory system
The control system
The energy system

www.dundee.ac.uk/orthopaedics/Imar2003

10. ERSIT)
al a,

DUNDEE

Institute of Motion Analysis & Research

The Structure:
The Musculo-skeletal System

11. A

¡Y 4 Institute of Motion Analysis & Research

“ru The Musculo-skeletal System

¢ Deformity
— Congenital e.g. club-foot

— Compensatory e.g.contracture
— latrogenic e.g... over lengthening of soft tissues
+ Abnormal growth
— e.g... Scoliosis, Limb length discrepancy, Torsional mal-
alignments CDH

+ Weakness
— Reflex inhibition due to pain

— Reciprocal inhibition secondary to abnormal tone

— Lower motor neurone lesion e.g... Dropped foot

www.dundee.ac.uk/orthopaedics/Imar2003

12. „SERSIT,
8 br Institute of Motion Analysis & Research

\
xa Muscles and the child’s growth

«Mass increases as a function of the cube.
«Strength increases as a function of the

square

This explains why many marginal walkers
go off their feet as they grow.

www.dundee.ac.uk/orthopaedics/Imar2003

13. Ro,

¡Y 4 Institute of Motion Analysis & Research
” DUNDEE The Motor System

+ The motor system comprises
the CNS and the efferent
components of the peripheral
nervous system.

+ They are primarily
responsible for the
transmission of signals
resulting in the initiation and
maintenance of muscular
contraction.

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14. „SERSIT,
8 br Institute of Motion Analysis & Research

\
punoee Damage to the Motor System

Neurological disorders: leads to potential
problems with:

— Loss of selective muscle control

— Dependence on primitive patterns

— Abnormal muscle tone

— Imbalance of agonists and antagonists

— Deficient equilibrium reactions EN

= Pi)
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ve 4 /

www.dundee.ac.uk/orthopaedics/Imar2003

15. NIERSIT,
$ a,

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Institute of Motion Analysis & Research

‘pue Damage to the Motor System

ap

AO

won

16. Ro,

¡Y 4 Institute of Motion Analysis & Research

| DUNDEE The Sensory System

« The sensory system comprises
the CNS and afferent
components of the peripheral
nervous system.

« They are responsible for
information regarding the status
of the limbs in terms of:

— Motion.

— Position sense,
— Acceleration,
— Temperature,
— Pressure etc.

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17. „SERSIT,
8 br Institute of Motion Analysis & Research

\
punpe@ Jamage to the Sensory System

« Damage to the sensory system in isolation
will not result in abnormal gait.
« However, it may present as a complication
with other motor disorders
— e.g. spina-bifida, peripheral neuropathies

9

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18. ERs,
Institute of Motion Analysis & Research

Y 4

DUNDEE The Control System

¢ The CNS in
conjunction with
feedback from the

ee
A
MA motor and sensory
E systems act to control
x the timing, rate and
intensity of muscle
pl activity.

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19. „SERSIT,
8 br Institute of Motion Analysis & Research

\

" punpeeLJamage to the Control System

+ Movement in largely determined by three
areas in the brain and abnormalities in these
will produce a particular pattern:

e Motor cortex Spasticity
+ Cerebellum Ataxia
+ Basal ganglia Dyskinesia

a

www.dundee.ac.uk/orthopaedics/Imar2003 A

20. ERSI7)
= a,

1

Institute of Motion Analysis & Research

pue The Cardio-vascular System

e All systems need
nourishment in order
to function normally.

« This is dependent on
normal cardiac and
pulmonary function.

www.dundee.ac.uk/orthopaedics/Imar2003

21. Institute of Motion Analysis & Research

oo,

¡Y _

LR Gait Deviations and
Possible Causes

« Is it a stance or swing phase problem

« Is it primary or secondary

DIN

www.dundee.ac.uk/orthopaedics/Imar2003

22. ERs,
Institute of Motion Analysis & Research

Y 4

DUNDEE Stance or Swing?

« The first consideration is to determine
which aspects of the gait cycle are
problematic.

« Problems arise in either or both the stance
and swing phases of gait.

« The demands on the body systems are quite
different for each.

www.dundee.ac.uk/orthopaedics/Imar2003

23. A

¡Y 4 Institute of Motion Analysis & Research

" DUNDEE Primary or Secondary

« Primary problems are the source of the
problem e.g knee arthrodesis

+ Compensations or coping responses result
from the primary problem and can
complicate the picture e.g... abnormality at
one level might affect the next level up or
down.

www.dundee.ac.uk/orthopaedics/Imar2003

24. ERs,
Institute of Motion Analysis & Research

Y 4

om Compensations
Primary Secondary
1. Knee arthrodesis 1. Hip circumduction
2. Spasticity of Rectus Femoris 2. Vaulting on other leg
3. Hip flexion contracture 3. Equinus of the ankle

www.dundee.ac.uk/orthopaedics/Imar2003

25. ERs,
Institute of Motion Analysis & Research

A
ES Gait Deviations

DUNDEE

+ Abnormal position or range of motion

¢ Contracture
— static
— dynamic

+ Muscle weakness

www.dundee.ac.uk/orthopaedics/Imar2003

26. ERs,
Institute of Motion Analysis & Research

A
E Trunk Sagittal

DUNDEE

+ Sagittal plane: increased tilt
Assists forward shift of the trunk

Walking with aides
Secondary to increased anterior pelvic

tilt
Excessive motion can compensate for abnormal
hip, knee or ankle movements or be a

consequence of poor balance.
ASA

www.dundee.ac.uk/orthopaedics/Imar2003

y

ee
AN

27. A

y 4 Institute of Motion Analysis & Research

DUNDEE Pelvis S agittal:

Anterior / posterior tilt

Hip flexor/extensor
tightness

Hip extensor weakness
Abdominal weakness

Lumbar kyphosis
Poor balance
Da

www.dundee.ac.uk/orthopaedics/Imar2003 A)

28. ERs,
Institute of Motion Analysis & Research

Y 4

DUNDEE Hip S agittal 5

Hip flexors vs. Extensors
Decreased flexion due to posterior pelvic tilt
+ Decreased extension due to anterior pelvic tilt

¢ Crouch gait
« Slow walking

CLI

www.dundee.ac.uk/orthopaedics/Imar2003 A)

29. „SERSIT,
8 br Institute of Motion Analysis & Research

\

punoee Hip excessively flexed?

+ Increased lordosis

« Knee flexion
« Hip flexion can produce compensations
distally.

www.dundee.ac.uk/orthopaedics/Imar2003

30. „SERSIT,
8 br Institute of Motion Analysis & Research

\

punpeLeviations at the Knee Sagittal:

« Multidirectional joint

¢ Interaction with the trunk and pelvis
+ Excessive flexion or extension

« Quadriceps vs. Hamstrings

+ Co-contraction

+ Capsular contracture

« Quadriceps weakness

« Gastrocnemius E
+ Rectus active in swing IT

www.dundee.ac.uk/orthopaedics/Imar2003

31. ERs,
Institute of Motion Analysis & Research

A
ES Knee Joint

DUNDEE

« Effectively a hinge joint

+ Sagittal plane only
+ Anomalies of flexion/extension

www.dundee.ac.uk/orthopaedics/Imar2003

32. ERs,
Institute of Motion Analysis & Research

A
ES Knee: Stance

DUNDEE

« Excessive flexion
— Muscle weakness
— Lever arm problems at the foot

« Mal-rotation
— Femoral anteversion

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33. Institute of Motion Analysis & Research

NERSIT;
$ a,

1
Knee extension in stance?

DUNDEE

« When
« Hyper-extension
¢ Persistent flexion

Normally extended just before initial
contact and then extends fully in stance

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34. „SERSIT,
8 br Institute of Motion Analysis & Research

\

Knee progression angle

DUNDEE

« Observe direction of progression in stance.
« Compare with foot progression angle in

swing.

www.dundee.ac.uk/orthopaedics/Imar2003

35. Institute of Motion Analysis & Research

A

4 \

‘pus Knee flexion in swing?
« Reduced

e Excessive

Normal range of motion 60°

www.dundee.ac.uk/orthopaedics/Imar2003

36. „SERSIT,
8 br Institute of Motion Analysis & Research

\

“ punpeeK nee angle at terminal swing?

«Flexed
«Extended

Normally fully extended prior to initial
contact and then flexes 15° during loading.

www.dundee.ac.uk/orthopaedics/Imar2003

37. ERs,
Institute of Motion Analysis & Research

A
< Knee: Swing

DUNDEE

+ Inadequate motion to allow foot clearance
+ Co-spasticity of Rectus Femoris and

Hamstrings

www.dundee.ac.uk/orthopaedics/Imar2003

38. A

Institute of Motion Analysis & Research

¡Y 4

‘ous Ankle and Foot Sagittal:

+ Triceps Surae
over action or
weakness

+ Weakness of
Tibialis
anterior

+ Over
lengthened
achilles tendon

a |

39. „SERSIT,
8 br Institute of Motion Analysis & Research

40. Institute of Motion Analysis & Research

Sn Tro.

A
ES Initial contact?

DUNDEE

«Heel
«Foot-flat
«Fore-foot

Normally initial contact is made with the
heel.

www.dundee.ac.uk/orthopaedics/Imar2003

41. „SERSIT,
8 br Institute of Motion Analysis & Research

\

punoee Foot plantegrade in stance

eEquinus
«Calcaneus
«Valgus
°Varus
«Neutral

Normally plantegrade until immediately before
opposite foot contact.

www.dundee.ac.uk/orthopaedics/Imar2003

42. „SERSIT,
8 br Institute of Motion Analysis & Research

\

Foot progression angle.

DUNDEE

+ Stance
¢ Swing

Normally 5° external

www.dundee.ac.uk/orthopaedics/Imar2003

43. EES
br Institute of Motion Analysis & Research

\
RA attitude at the end of swing.

si
Ss

eLevel
eVarus
«Valgus

Normally level, neutral or in slight

dorsiflexion.

www.dundee.ac.uk/orthopaedics/Imar2003

44. „SERSIT,
8 br Institute of Motion Analysis & Research

\

“pu Ankle and foot: Equinovarus

Seen usually in hemiplegia.
Heel lies in equinus and varus

Mid-foot is supinated
Fore-foot adducted and pronated

www.dundee.ac.uk/orthopaedics/Imar2003

45. Institute of Motion Analysis & Research

NERSIT;
$ a,

1
KA Ankle and foot: Equinovarus

¢ Medial column is short

« Deformity may be mobile or fixed
— Mobile: calcaneal osteotomy or sub-talar fusion

— Fixed: triple fusion

www.dundee.ac.uk/orthopaedics/Imar2003

46. Institute of Motion Analysis & Research

\
R A Ankle and foot: Equinovalgus

NERSIT;
$ a,

+ Heel lies in equinus and valgus
« Mid-foot is pronated and appears ‘broken

« Fore-foot is abducted and supinated.

www.dundee.ac.uk/orthopaedics/Imar2003

47. Institute of Motion Analysis & Research

NERSIT;
$ a,

1
xa Ankle and foot: Equinovalgus

« Lateral column is short
Deformity may be mobile or fixed

e
— Mobile: lengthening calcaneal osteotomy or

sub-talar fusion
— Fixed: triple fusion

www.dundee.ac.uk/orthopaedics/Imar2003

48. Institute of Motion Analysis & Research

Ya Ankteand-foot-
~ Gait Deviation

+ Equinovarus
— instability in stance due to excessive loading of

the lateral side of the foot and a resultant
narrow base of support

« Equinovalgus
— externally rotated foot progression angle, lever

arm deficiency for the plantarflexors and a
narrow base of support

www.dundee.ac.uk/orthopaedics/Imar2003

49. „SERSIT,
8 br Institute of Motion Analysis & Research

\

“punvee Deviations of the Trunk Coronal:

Increased motion

Abductor insufficiency
e Assists transfer on to stance limb

Trendelenburg and Duchenne patterns
Walking with aides
« Scoliosis may produce a fixed lateral lean

x,
CLI

www.dundee.ac.uk/orthopaedics/Imar2003 A)

50. ERs,
Institute of Motion Analysis & Research

A
E Trendelenburg

DUNDEE

+ Contralateral pelvic drop

« Hip at risk

www.dundee.ac.uk/orthopaedics/Imar2003

51. ERs,
Institute of Motion Analysis & Research

A
ES Duchenne

DUNDEE

¢ Ipsilateral trunk lean

« Protects hip

www.dundee.ac.uk/orthopaedics/Imar2003

52. si
Ss

EES
br Institute of Motion Analysis & Research

\
Deviations of the Pelvis Coronal:

DUNDEE

e Adductor vs. Abductors

+ Scoliosis
« Leg length discrepancy

x,
FI

www.dundee.ac.uk/orthopaedics/Imar2003

53. ERs,
Institute of Motion Analysis & Research

Y 1
‘»æDeviations at the Hip Coronal:

« Abductors vs. adductors

+ Scoliosis
« Leg length discrepancy

NG

www.dundee.ac.uk/orthopaedics/Imar2003

54. FS
=
3
4
El
%

%

55. ¡ERSIT)
ON

1

S
= Institute of Motion Analysis & Research

punoee Hip adduction in Swing?

«Normal
«Excessive
*Trunk rotation

Adduction may present as pelvic obliquity
or apparent shortening.

Excessive femoral anteversion can appear
like adduction.

www.dundee.ac.uk/orthopaedics/Imar2003

56. SBRSI7)
SS ON

...
e. . ©

DUNDEE

\

Institute of Motion Analysis & Research

Rotation or Adduction?

57. „SERSIT,
8 br Institute of Motion Analysis & Research

\
R Dee and Foot Coronal Plane:

+ Hind-foot varus or valgus
+ Mid-foot abduction
« Forefoot adduction

NG

www.dundee.ac.uk/orthopaedics/Imar2003

58. „SERSIT,
8 br Institute of Motion Analysis & Research

\

punveE Foot and ankle in stance.

« Varus or valgus deformity

¢ Restricted 2™ rocker - overactive Triceps
Surae

¢ Excessive 2" rocker - weak Triceps Surae,
mid foot break

www.dundee.ac.uk/orthopaedics/Imar2003

59. EES
br Institute of Motion Analysis & Research

\
er Heels - Pronated Feet?

si
SÍ

60. ...
e. . ©

yERSIT)
ss ON

DUNDEE

Institute of Motion Analysis & Research

61. Institute of Motion Analysis & Research

62. ERs,
Institute of Motion Analysis & Research

Y
DUNDEE Trunk Transverse:

« Increased motion may be used to help
forward progression, and when walking
with aides.

« Asymmetrical rotation may be seen in
hemiplegia or scoliosis.

CLI

www.dundee.ac.uk/orthopaedics/Imar2003 A)

63. NERSIT,;
> Tes

Institute of Motion Analysis & Research

\

DUNDEE

Pelvis Transverse Plane:

« Retraction and protraction

¢ Femoral rotation

x,
SEÑA

www.dundee.ac.uk/orthopaedics/Imar2003

64. „SERSIT,
8 br Institute of Motion Analysis & Research

\

DUNDEE

Hip Transverse Plane:

¢ Femoral torsion internal or external

« Pelvic rotation
¢ Tibial torsion may also affect hip position

x,
Pils

www.dundee.ac.uk/orthopaedics/Imar2003

65. ERs,
Institute of Motion Analysis & Research

Y 4

DUNDEE Femoral anteversion:

Increased foot progression angle
Functional shortening of the abductor lever
arm

Abnormal patello-femoral mechanics

« Secondary external tibial torsion

www.dundee.ac.uk/orthopaedics/Imar2003

66. ¡ERSID,
So a,

Institute of Motion Analysis & Research

67. SE,

Y A

DUNDEE

Institute of Motion Analysis & Research

Rotation or Adduction?

68. + Institute of Motion Analysis & Research
vunkle and Foot Transverse Plane:

+ Excessive pronation or supination

« Internal or external progression usually
secondary to -

« Femoral or tibial torsion's

Pils

www.dundee.ac.uk/orthopaedics/Imar2003 A)

69. ERs,
Institute of Motion Analysis & Research

A
ES Tibial Torsion:

DUNDEE

* Diminished plantarflexor moment produced
by Gastrocnemius and Soleus

www.dundee.ac.uk/orthopaedics/Imar2003

70. SE,

Y 4

DUNDEE

Institute of Motion Analysis & Research

71. SERSIT,
$ a,

Sa

\

Institute of Motion Analysis & Research

pundsxcessive External Tibial Torsion

d
a
y

[M

72. ERs,
Institute of Motion Analysis & Research

A
ES Ankle Joint

DUNDEE

« Primarily a hinge joint

+ Sagittal plane only
« Anomalies of plantar and dorsiflexion

www.dundee.ac.uk/orthopaedics/Imar2003

73. ERs,
Institute of Motion Analysis & Research

Y 4

DUNDEE Message.

DO not think of isolated muscle groups.
+ Interactions occur across planes

+ Interactions occur at different anatomical
levels

Do not forget the swing phase

www.dundee.ac.uk/orthopaedics/Imar2003