UNDERSTANDING NORMAL & PATHOLOGICAL
GAIT
Mahmoud Sarmini, M.D. Assistant Prof. LSU-PM&R
Objectives:
Basis
for Dx & Rx of pathological gait Rational prescription of orthotic devices Understanding & correction of prosthetic ambulation
Gait Cycle - Definitions:
Normal
Gait =
Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity series of controlled falls
Gait Cycle - Definitions:
Gait
Cycle =
Single sequence of functions by one limb Begins when reference font contacts the ground Ends with subsequent floor contact of the same foot
Gait Cycle - Definitions:
Step
Length =
Distance between corresponding successive points of heel contact of the opposite feet Rt step length = Lt step length (in normal gait)
Gait Cycle - Definitions:
Stride
Length =
Distance between successive points of heel contact of the same foot Double the step length (in normal gait)
Gait Cycle - Definitions:
Walking
Base =
Side-to-side distance between the line of the two feet Also known as stride width
Gait Cycle - Definitions:
Cadence
Number of steps per unit time Normal: 100 115 steps/min Cultural/social variations
Gait Cycle - Definitions:
Velocity =
Distance covered by the body in unit time Usually measured in m/s Instantaneous velocity varies during the gait cycle Average velocity (m/min) = step length (m) x cadence (steps/min)
Comfortable Walking Speed (CWS) =
Least energy consumption per unit distance Average= 80 m/min (~ 5 km/h , ~ 3 mph)
Gait Cycle - Components:
Phases:
(1)Stance Phase: reference limb in contact with the floor (2) Swing Phase: reference limb not in contact with the floor
Gait Cycle - Components:
Support:
(1) Single Support: only one foot in contact with the floor (2) Double Support: both feet in contact with floor
Gait Cycle - Subdivisions:
A. Stance phase:
1. 2. 3. 4. 5. Heel contact: Initial contact Foot-flat: Loading response, initial contact of forefoot w. ground Midstance: greater trochanter in alignment w. vertical bisector of foot Heel-off: Terminal stance Toe-off: Pre-swing
Gait Cycle - Subdivisions:
B. Swing phase:
1. Acceleration: Initial swing 2. Midswing: swinging limb overtakes the limb in stance 3. Deceleration: Terminal swing
Gait Cycle
Time
Frame: A. Stance vs. Swing: Stance phase = 60% of gait cycle Swing phase = 40% B. Single vs. Double support: Single support= 40% of gait cycle Double support= 20%
With
Running: By definition: walking without double support Ratio stance/swing reverses Double support disappears. Double swing develops
Stance phase: Swing phase: Double support:
increasing walking speeds:
decreases increases decreases
Path of Center of Gravity
Center
of Gravity (CG):
midway between the hips Few cm in front of S2
Least
energy consumption if CG travels in straight line
CG
Path of Center of Gravity
A. Vertical displacement:
Rhythmic up & down movement Highest point: midstance Lowest point: double support Average displacement: 5cm Path: extremely smooth sinusoidal curve
Path of Center of Gravity
B. Lateral displacement:
Rhythmic side-to-side movement Lateral limit: midstance Average displacement: 5cm Path: extremely smooth sinusoidal curve
Path of Center of Gravity
C. Overall displacement:
Sum of vertical & horizontal displacement Figure 8 movement of CG as seen from AP view
Vertical plane Horizontal plane
Determinants of Gait :
Six
optimizations used to minimize excursion of CG in vertical & horizontal planes Reduce significantly energy consumption of ambulation Classic papers: Sanders, Inman (1953)
Determinants of Gait :
(1) Pelvic rotation:
Forward rotation of the pelvis in the horizontal plane approx. 8o on the swing-phase side Reduces the angle of hip flexion & extension Enables a slightly longer step-length w/o further lowering of CG
Determinants of Gait :
(2) Pelvic tilt:
5o dip of the swinging side (i.e. hip adduction) In standing, this dip is a positive Trendelenberg sign Reduces the height of the apex of the curve of CG
Determinants of Gait :
(3) Knee flexion in stance phase:
Approx. 20o dip Shortens the leg in the middle of stance phase Reduces the height of the apex of the curve of CG
Determinants of Gait :
(4) Ankle mechanism:
Lengthens the leg at heel contact Smoothens the curve of CG Reduces the lowering of CG
Determinants of Gait :
(5) Foot mechanism:
Lengthens the leg at toe-off as ankle moves from dorsiflexion to plantarflexion Smoothens the curve of CG Reduces the lowering of CG
Determinants of Gait :
(6) Lateral displacement of body:
The normally narrow width of the walking base minimizes the lateral displacement of CG Reduced muscular energy consumption due to reduced lateral acceleration & deceleration
Gait Analysis Forces:
Forces
which have the most significant Influence are due to:
(1) (2) (3) (4) gravity muscular contraction inertia floor reaction
Gait Analysis Forces:
The force that the foot exerts on the floor due to gravity & inertia is opposed by the ground reaction force Ground reaction force (RF) may be resolved into horizontal (HF) & vertical (VF) components. Understanding joint position & RF leads to understanding of muscle activity during gait
Gait Analysis:
At initial heel-contact: heel transient At heel-contact:
Ankle: Knee: Hip: DF Quad Glut. Max&Hamstrings
Gait
Initial HC Heel transient
HC
Foot-Flat
Mid-stance
Gait
Initial HC HeelHeel-off transient
HC Toe-off
GAIT
Low
muscular demand:
~ 20-25% max. muscle strength MMT of ~ 3+
COMMON GAIT ABNORMALITIES
A.
B.
C. D. E. F.
Antalgic Gait Lateral Trunk bending Functional Leg-Length Discrepancy Increased Walking Base Inadequate Dorsiflexion Control Excessive Knee Extension
Dont walk behind me, I may not lead. Dont walk ahead of me, I may not follow. Walk next to me and be my friend.
Albert Camus
COMMON GAIT ABNORMALITIES:
A. Antalgic Gait
Gait
pattern in which stance phase on affected side is shortened Corresponding increase in stance on unaffected side Common causes: OA, Fx, tendinitis
COMMON GAIT ABNORMALITIES:
B. Lateral Trunk bending
Trendelenberg
gait Usually unilateral Bilateral = waddling gait Common causes:
A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint
Ex. 2: Hip abductor load & hip joint reaction force
Ex. 2: Hip abductor load & hip joint reaction force
C. Functional Leg-Length Discrepancy
Swing
COMMON GAIT ABNORMALITIES:
leg: longer than stance leg 4 common compensations:
A. Circumduction B. Hip hiking C. Steppage D. Vaulting
D. Increased Walking Base
Normal
COMMON GAIT ABNORMALITIES:
walking base: 5-10 cm Common causes:
Deformities
Abducted
hip Valgus knee
Instability
Cerebellar
ataxia Proprioception deficits
E. Inadequate Dorsiflexion Control
In
COMMON GAIT ABNORMALITIES:
stance phase (Heel contact Foot flat): Foot slap In swing phase (mid-swing): Toe drag Causes:
Weak Tibialis Ant. Spastic plantarflexors
F. Excessive knee extension
Loss
COMMON GAIT ABNORMALITIES:
of normal knee flexion during stance phase Knee may go into hyperextension Genu recurvatum: hyperextension deformity of knee Common causes:
Quadriceps weakness (mid-stance) Quadriceps spasticity (mid-stance) Knee flexor weakness (end-stance) * * *
