Gait Flashcards
Why Gait Analysis
Comparison to normal
Develop hypotheses as to underlying mechanisms causing observed dysfunction
Classification of severity of disability
Prediction of future status (gait speed prosthetic non-se)
Determine need for devices/equipment (adaptive/orthotic/prosthetic, assistive/protective/supportive) and effectiveness/fit of selected devices/equipment
Assess effectiveness of intervention
Observational Gait Analysis
Advantages - easy to perform in any clinical environment, time efficient, low cost, initial impression can be gleaned
Disadvantages - tendency to focus on eye gross deviations while overlooking subtle ones, depends on experience and individual bias, reliability and validity and interrater assessments, qualitative
Systematic Gait Analysis
Anatomical sequence of observation to sort multiple events at different jts (start at foot and move up, right before left)
Phasing of gait (swing vs. stance)
Stay focused and organized - don’t jump ahead
When referring to pelvis/trunk (reference to stance leg)
Reliability of OGA
Low to moderate reliability
To improve reliability - videotape clients (can slow down or pause tape, avoid client fatigue by repetitive walking)
Training
Experience
Developmental Acquisition
11-15 months - avg onset of independent walking
24 months - consistent heel strike, push off absent
30-36 months - reciprocal arm swing
BOS decreases after 4-5 months of independent walking (abd decreases first, ER last component to decrease)
Temporal phasing (swing to stance) - 50/50
Mature walking pattern by 4-5 years of age
Gait Changes Noted in Elderly
Mild stiffness, greater proximally (decreased rotation at pelvis and trunk)
Decreased arm swing (increased shoulder ext and elbow flex) - guard position
Decreased speed (decreased jt velocity)
Increased cadence - more steps
Decreased step length (decreased swing excursion, increased stance phase and double support time)
Stride width is increased (hip abd increased, greater toeing out) - increased BOS to keep balance
Increased toe-floor clearance (sl. stoppage)
Decreased heel strike (less DF thru/out)
5 Pathological Mechanisms
Deformity (includes decreased ROM)
Muscle weakness
Sensory loss
Pain - antalegic gait
Impaired motor control
All of these can happen in combinations
Pathological Mechanisms: Deformity - Contracture
Structural change w/in fibrous connective tissues of muscle, ligaments, or joint capsule following inactivity or scarring (inactivity or limited mobility)
Ankle-PF Contracture
Most common
Obstructs progression of leg during stance, inhibits foot clearance
Toe touch walking
Hyperext of knee
Knee Flex Contracture
Inhibits advancement of thigh
Knee Ext Contracture
Increases energy expenditure due to compensations to clear floor
Hip Flexion Contracture
Most common
Increases strain on back and hip extensors
Anterior pelvic tilt, lumbar lordosis is accentuated
Pathological Mechanisms: Muscle Weakness
Disuse
Neurological impairment
Strength-when patient tests 5/5
Gait deviations
- Decreased speed
- Substitutions
Pathological Mechanisms: Sensory Loss
Proprioceptive impairments
Light touch and deep pressure
Gait deviations
- Decreased speed
- Substitute by locking knee
- Hitting the floor loudly
- Visual monitoring of legs/feet
Pathological Mechanisms: Pain
Attempt to reduce compressive & shear forces
Excessive tissue tension leads to deformity and weakness
Deformity-moves into position of comfort of intra-articular pressure
- Ankle 15° plantarflexion
- Knee 30-45° flexion
- Hip 30° flexion
Weakness-secondary to joint swelling which causes disuse atrophy
Pain shuts off any muscle
Pain – results in muscle loss and deformity/decreased ROM
Pathological Mechanisms: Impaired Motor Control - Spasticity
Obstructs yielding quality of eccentric muscle activity during stance
Soleus/gastroc cause persistent ankle plantarflexion-loss of ankle rocker
Hamstrings limits effective terminal swing and restricts thigh advancement in stance
Hip flexors restrict progression in mid and terminal stance
Quadriceps inhibits pre-swing prep for limb advancement
Spasticity brings leg back
Jt going fast - spasticity wants to slow it
Pathological Mechanisms: Impaired Motor Control - Decreased Selective Control
Timing
Intensity
Muscles active at the wrong time
Pathological Mechanisms: Impaired Motor Control - Primitive Locomotor Patterns
Massed extension
Massed flexion
Keep in synergy
Pathological Mechanisms: Impaired Motor Control - Impaired Phasing
Due to control errors and spasticity
Action of muscles are prolonged, curtailed, premature, delayed, continuous, and/or absent
Results in substitutions
Gait Speed
If energy requirements are increased, speed is adjusted - too slow or too fast
Realize that
- Arm swing is related to velocity (normally, no arm swing during slow walking)
- UEs assist w/ balance
Propulsive Gait
CO2 poisoning, drug side effects
Stooped rigid posture w/ head and trunk flexed forward
Parkinson’s gait - short rapid steps (festinating), rigidity w/ no arm swing, difficulty w/ starting, stopping, turning
Steppage Gait
Exaggerated hip and knee flex w/ foot drop or foot slap
Ankle DF weakness (peroneal nerve damage, polyneuropathy, polio, MS, herniated disc L5, GBS)
Waddling Gait
Toes pointed out, wide BOS
Duck-like walk that may appear in childhood or later in life
Congenital hip dysplasia, muscular dystrophy, spinal muscular atrophy
Through whole gait cycle
Ataxic Gait
Cerebellar disorders, severe sensory deficits of LEs
Wide BOS, uncoordinated mvts, lurching/staggering, increased trunk mvts and variable foot placement
Wide base and negative base periods
Spastic or Scissoring Gait
CVA, TBI, SC trauma, meningomyelitis, MS, CP
Secondary to hypertonicity of LEs (higher energy requirements, unsteady)
Over-activity of hip adductors w/ narrow, crossing BOS
Negative space Negative BOS Leg has to go in front and over Can get friction burns between knees Adduction and IR with extension synergy Over-activity of hip adductors – weakness in glut med
Hemiplegic Gait
UE (shoulder adduction and flexionelbow, wrist, and finger flexion)
LE (extensor synergy: hip extension, add., IR; knee extension; ankle plantarflexion with inversion (equinovarus); flexor synergy: hip flexion, abd., ER; knee flexion; ankle dorsiflexion)
Slow velocity, dec. stance time on involved limb and step length on uninvolved side
Difficulty with limb stability (knee collapse or knee hyperextension)
Difficulty with limb clearance (decreased flexion, toe drag)-substitute with hip hiking/circumduction
Difficulty with limb advancement (decreased knee extension, pelvic retraction)
Swing phase - leg comes up and out
Glut Max Gait (Lurching)
Backward lurch of trunk just after initial contact
Hyperextension of hip with forward ‘protrusion’
Vector behind hips and pushes them forward – glut max
Gluteus Medius/Trendelenberg Gait
Uncompensated - contralateral pelvic drop at initial contact of affected side
Compensated - lateral trunk flex/lean, steppage gait
Antalgic Gait - Hip
Avoidance of WB on affected side
Stance - decreased stance phase, trunk lurch toward painful hip, heel strike avoided to prevent jarring and excess loading
Swing - flexed, ER, abd (relaxed jt capsule)
Antalgic Gait - Knee
Maintained in slight flexion throughout
Avoidance of heel strike
Toe walking on affected side
Antalgic Gait - Foot and Ankle
Stride length shortened
Normal heel-to-toe lost
- Forefoot avoid toe off
- Ankle or hindfoot avoid heel strike
Gait Deviation: Swing - Excessive Hip Flexion
Foot drop
Flexor synergy (control problem)
Gait Deviation: Swing - Limited Hip Flexion
Decreased step length
Decreases knee flexion
Weak hip flexors (grade 2+ is sufficient)
Extensor spasticity
Pain
Gait Deviations: Swing - Circumduction
BOS is normal
Weak hip, knee, and/or ankle flexors
Only occurs during swing
Gait Deviations: Swing - Hip Hiking (Pelvic Mvt)
Lack of knee flexion and/or ankle DF
Compensation for extensor spasticity of swing leg
Leg length discrepancy
Gait Deviations: Swing - Limited Knee Flexion
Pain (avoid shearing and compressive forces)
Decreased range
Weak knee flexor/lack of pressing flexion
Extensor spasticity
Proprioceptive deficit
Gait Deviations: Swing - Lacks Knee Ext in Terminal Swing
Flexor synergy
Weak quads
Knee flex contracture
Decreased gait velocity
Proprioceptive deficits
Gait Deviations: Swing - Excessive Knee Flexion
Flexor synergy
Gait Deviations: Swing - Limited Ankle DF
Weak DF - result in decreased ROM
Decreased range
Spasticity
Proprioceptive deficits
Gait Deviations: Swing - Toe Drag
Weakness of DF and toe extensors
Spasticity of PFs
Inadequate hip/knee flex
Stay in PF position
Gait Deviations: Initial Contact - Limited Hip Flex
Weak hip flexors or glut max
Decreased range
Gait Deviations: Initial Contact - Excessive Hip Flex
Hip and/or knee flexion contracture
Spasticity in hip flexors
Weakness in soleus/gastroc (allows tibia to travel forward - see inc. hip and knee flex)
Gait Deviations: Initial Contact - Excessive Knee Flex
Knee flex contracture (mvt is same through gait cycle)
Hamstring spasticity (muscle turns on and off, changes through gait sped)
Weakness in quads (collapse)
Impaired proprioception
Leg length discrepancy (to shorten contralateral longer leg)
Pain
Gait Deviations: Initial Contact - Excessive Ankle PF
Dependent on severity - foot slap, low heel strike, flat foot contact, forefoot contact
Weak DFs
Extensor spasticity
PF contracture
Leg length (to lengthen short ipsilateral leg)
Painful heel (toes first)
Fixed DF (fixed ankle orthosis)
Glut med/max problems - usually ankle PF
Little weakness in tib ant - less heel strike
Flat foot - don’t use tib ant
Toe-heel gait - don’t DF - touch w/ toe, then heel, hyperext at knee
Gait Deviations: Loading - Excessive Hip Flex w/ APT
May lean trunk backwards to compensate
Weak hip extensors
Gait Deviations: Loading - Knee Hyperextension
Weak quads
Impaired proprioception
Spastic quads/PFs
Compensation for PF contracture
Gait Deviations: Loading - Excessive Knee Flexion
Knee flex contracture
Spastic hamstrings
Impaired proprioception
Gait Deviations: Stance - Lateral Trunk Lean
Lateral trunk lean toward stance leg, contralateral pelvic drop
May look like hip hike in stance (hip hike only occurs in swing)
Painful hip
Weak glut med of stance
Gait Deviations: Stance - Backward Trunk Lean, APT
Weak glut max on stance leg
Gait Deviations: Stance - Forward Trunk Lean
Compensation for quad weakness
Hip and/or knee flex contracture
Gait Deviations: Stance - Limited Hip Extension
Hip flexion contracture/arthrodesis
Spasticity in hip flexors
Gait Deviations: Stance - Hip Abduction
Contracture of glut med
Gait Deviations: Stance - Hip Adduction
Spasticity in hip adductors (also in flexors)
Gait Deviations: Stance - Excessive Knee Flex
Knee flex contracture
Flexor synergy
Flexor withdrawal reflex
Weak PFs
Gait Deviations: Stance - Excessive DF, no heel off
Weak PFs (eccentric)
Hip and/or knee flex contractures
Gait Deviations: Push-Off - Limited Knee Flex
Spasticity in quads and/or PFs
Gait Deviations: Push-Off - Early Heel Rise
Spasticity of PFs
Decreased DF range
Gait Deviations: Push-Off - Lack of Roll Off
PF weakness
Forefoot pain
Limited forefoot motion
Excessive PF
Limb is longer - toe drags/catches
Stance - loss of progression - shortened stride length and reduced gait velocity
Swing - obstructs limb advancement - substitutions as result of increased limb length and body effort, shortened step length
Initial contact - low heel contact (decreased rocker), forefoot > 20 places forefoot lower than heel
Loading - decreased heel rocker, decreased knee flex (hyperext knee)
Midstance - inhibits tibial advances - compensations: premature heel-off (faster gait speed), knee hyperext, forward trunk lean (slower gait speeds)
Midswing - toe drag - compensations: increased hip flex w/ knee flex, circumlocution, lateral trunk lean (hip hike), contralateral vaulting
Excessive DF
Slower walking speed, excessive knee flex, crouched position
Stance - shortened step length, increased quad demand
Loading (throws body forward - need to have good quads) - increased flex moment, contact w/ foot flat and eliminating normal PF
Midstance - instability at onset of single limb support, increased quad demand
Preswing - prolonged heel contact
Soleus Weakness
Cause excessive DF
Soleus holds tibia back during gait - stabilizes tibia to have controlled loading
Weak soleus - tibia goes forward way too fast
Excessive Inversion (Varus)
Lateral forefoot loading
Premature heel-off in mid stance
Causes - overactivity of soleus, PF contracture, tib ant/toe extensor, flexor hallicus/flexor digitorum activity (toe clawing), weakness of perennials (muscle imbalance)
Excessive Eversion (Valgus)
Shortened heel on at IC
Excessive DF secondary to unlocking of mid tarsal jts
Center of pressure moved medially in terminal stance and preswing
Causes - weakness in invertors
Pronation, unstable foot
Foot loses arch and goes in other direction - rocker bottom foot
Some so locked - resting on navicular
Inadequate Knee Flex
Loading - limits shock absorption, absent knee flex is usually substitutive for quad weakness (hyperext)
Pre-Swing - makes toe-off harder, lift LE by increasing hip flexion (increased DF and heel contact prolonged)
Initial swing - toe drag (circumduction, hip hiking, vaulting on opp side)
Excessive Ext (Recurvatum)
Extensor thrust - snapping action
Dynamic retraction to substitue for weak quads (grade 3+ to 4) - by soleus to retract tibia, by glut max to retract femur, used to maintain speed and endurance
Quad Weakness
Terminal swing - fast retraction of hip (glut max) will extend knee
Loading - knee flex avoided, tibial advancement by soles and/or glut max
Stance - hyperext used to increase heel contact, may see forward trunk flex to increase anterior vector
Pre-swing - knee ext maintained until other foot is fully loaded (double support increased to feel safer)
Inadequate Extension
Shortened step length
Increased quad demand
Inappropriate actions of hamstrings - spasticity, substitution for glut max (see mild loss of knee flex due to action of tibia)
Soleus weakness - tibia advances too fast (also see ankle DF and sustained heel contact)
Hamstrings give resistance - knee comes back into flex after it’s kicked out (at very high speed, usually from mid swing to terminal swing)
Genu Valgum
Lateral tilt of distal tibia w/ lateral displacement of foot (knock knees)
Distance b/w feet is greater than at knees
False impression of valgus - hip IR, add and knee flex
Seen in RA
Genu Varus
Medial tilt of distal tibia w/ medial displacement of feet (bowleg)
Distance b/w knees greater than at feet
False impression of varus caused by hip ER, abd and knee flexion
Seen in OA
Inadequate Hip Extension
Mid-stance - modifies alignment of hip.thigh, compensations - lumbar lordosis (adults < 15, children 30 hip flex), knee flex (reduces body progression/increased demand on quads)
Increased demand of hip extensors
Terminal stance - body advancement and step length shortened, thigh unable to trail
Hip flex tightness - cause lots of problems
30 degrees - crouched gait
Lordosis - if there is 15 degrees, get hip flex contracture (occurs first, anterior pelvic occurs)
Inadequate Hip Flexion
Decreased step length and speed
Substituions - posterior pelvic tilt (uses abs if hip flexors are weak), circumlocution, hip hiking, voluntary excessive knee flex, contralateral vaulting and lateral lean of trunk to opp side
Excessive Adduction
Scissoring gait - part of extensor synergy (assoc w/ hip flex and IR), narrow BOS, blocks progression of swing leg
Adductor contracture - does not correct thru gait cycle
Abductor weakness < 3 - corrects in preswing s weight is transferred to opposite limb
Adductor use as hip flexor - medial displacement of tight in swing
Excessive Abduction
Wide BOS
Increased stance stability (balance impairments) - requires greater effort to shift weight from one limb to another
During swing, action increases floor clearance - circumduction substitutes for decreased hip flex
Other causes - abduction contracture, short leg (along w/ ipsilateral pelvic drop to lengthen leg)
Waddle gait
Excessive Rotation - External
ER or IR - limited PF length (avoid stretch)
Weak IR
Backward pelvic rotation
Overactive glut med
Compensate for quad weakness
Use adductors as hip flexor
Using peroneals/fibulari as PFs
Excessive Rotation - Internal
ER or IR - limited PF length (avoid stretch)
Weak ER
Forward pelvic rotation
Medial hamstring over activity
Adductor over activity (w/ hip flex, hip adductors cause IR)
Anterior abductor activity (TFL, ant GM)
Quad weakness (IT band and lateral knee ligaments resist flex of knee)
Pelvic Tilt
Anterior - weak hip extensors, hip flex contracture
Posterior - substitute action for limited hip flex
Pelvic Hike and Drop
Hike - assist foot clearance, substitute for weak hip
Contralateral drop - weak hip abductors, hip adductor contracture or spasticity (at mid stance - pelvis is drawn as femur assumes vertical)
Ipsilateral drop - contralateral abductor weakness, short limb, calf muscle weakness (decreases heel rise - short limb), scoliosis
Uncompensated - drop
Compensated - ipsilateral lean to weak side
Excessive Pelvic Rotation
Forward - advance limb when hip flexors are weak, also IR but doesn’t cross neutral line
Backward - in terminal stance, calf muscle weakness results in lack of heel rise (shortened limb) - not good push off, pelvis retracts more
Lack of rotation - rigid spine w/ stiff gait
Backward Lean
Hip extensor weakness - begins at loading and continues through stance, bilateral (during entire stride)
Inadequate hip flex - assist limb advancement when lumbar spine is immobile or abs are weak (use pelvis to kick forward)
Forward Trunk Lean
Ankle PF - anterior vector moves forward over area of foot support
Quad weakness - anterior vector moves forward to force knee ext
Glut max weakness - pelvis falls forward and trunk follows (first APT, then trunk leans forward)
Ipsilateral Trunk Lean
Toward stance limb - compensate for weak hip abduction (begins w/ loading and ends at terminal stance), hip adductor contracture - to correct, trunk leans to stance limb (if ITB tightness, will see trunk flex also), short limb, scoliosis
Toward swing limb - impaired body image (incompatible w/ stability), assist during swing to clear limb
Excessive Trunk Rotation
Increased energy cost
Causes - synergy (no counterbalance forward rotation of ipsilateral trunk), walking aid synergy (trunk follows cane), arm swing (excessive arm swing used to assist balance)
