GAIT CYCLE AND PATHOLOGICAL GAIT

MODERATOR :DR.PRAMOD B ITAGIPROFESSOR & UNIT HEAD

DEPARTMENT OF ORTHOPAEDICSMRMC GULBARGA

PRESENTER :DR.RAMACHANDRA

• INTRODUCTION• NEUROLOGICAL CONTROL OF GAIT• DIVISION OF GAIT CYCLE• KINEMATICS• DETERMINANTS OF GAIT• MUSCLE ACTIVITY• KINETICS OF GAIT• BENEFITS OF GAIT ANALYSIS

GAIT CYCLE

INTRODUCTION:A systematic approach to gait analysis i,e,

looking at trunk & each joint moving in all three planes i,e. saggital,coronal & transverse.

It can yield valuable information about patient's condition & help in establishing a treatment plan.

The earliest work on gait was done by BORELLI in 1682.

The WEBBER brothers in Germany gave first clear description of GAIT CYCLE GAIT CYCLE in1836.

In 1940 SCHERB from Switzerland studied various muscle activity during different parts of gait cycle,using treadmill & later by EMG.

DEFINITION:

• The gait may be definied as forward propulsion of body by lower limbs in a systemic,coordinated semi-rotatory movements of trunk, arm & head.

GAIT ANALYSIS • The science of studying human gait is

GAIT ANALYSIS , which is done in terms of– Movement in space– Metabolic energy– Functional muscle patterns– Interaction of forces

GAIT CYCLEGAIT CYCLE• The duration that occurs from the time

when the heel of one foot strikes the ground to the time at which the same foot contacts the ground again.

• Normally 1-2 sec.• Two phases: 1.Stance phase-60% 2.Swing phase-40%

STANCE PHASE :Defined as the time during which the limb

is in contact with the ground and supporting the weight of the body.

SWING PHASE:Defined as the time period during which

the limb is off the ground and advancing forward,the body weight supported by contralateral limb.

NEUROLOGICAL CONTROL OF GAIT

• Motor Cortex Voluntary modulation of gait.Eg:Alter in speed,change in direction.

•Cerebellum

•Extrapyramidal tract

Controlling Balance

Responsible for most complex unconscious pathways

Spinal Cord

Golgi Tendon UnitsMuscle Spindle,Joint

Reflex Stepping Movements

Produce neurologic feedback & serve as dampening devices for coordination of gait.

TEMPORAL PARAMETERS

Distance and time measurements calculated during gait analysis are referred to as CADENCE PARAMETERS.

It includes

STANCE PHASE1)Initial contact ( heel

strike)

• Heel contacts the ground first

• Hip is flexed at 30 degrees.

• Knee is extended and the

ankle is neutral (or slightly plantar flexed)

2) Loading response Occupies 10-15% of gait cycle.

• Shock absorption is a primary action.

• Ends with contralateral toe off 

• Knee flexes 15 deg while ankle plantar flexes 15 degrees.

3) Midstance • Occupies 15-20%.• Body is directly over

weight bearing leg.• Pelvis has ceased

rotating forward.• Hip & knee full extension.• Ankle is at neutral with

foot in ground contact.

4) Terminal stance • Occupies 20 -25%.• Contralateral side of

pelvis rotates forward.• Hip & knee remain in

extension.• Foot is in neutral or

plantar flexed.

5) Pre-swing • Occupies 5-10%.• Knee of weight bearing

limb flexes & prepares for swing phase.

• Hip in neutral position.• Knee flixion upto 35

degrees.• Ankle plantar flexed at

20 degrees.

SWING PHASE• 1) Initial swing • Occupies 5-10%• Begins at toe off and

continues until maximum knee flexion (60 degrees) occurs

• Ankle moves up to 10 degrees plantar flexion.

• 2) Mid-swing • Occupies 20-30%• Knee extension

occurs by reducing flexion of initial swing from 70 degr to 30 degr.

• The ankle & foot are brought upto neutral position.

3) Terminal swing • Occupis 5-10%• Pelvis rotetes forward

hip flexion reaches 30 degr, knee extend to near 0 degr.

• Ankle maintains neutral position.

KINEMATICS• It is definied as study of angular rotations

of each joint during movement.• It can be observed & measured at

foot,ankle, knee & hip during gait cycle.• Observed in three planes Sagittal:hip flexion,extension Coronal:hip abduction,adduction Transverse:hip rotation,tibia,foot.

SAGITTAL PLANE:• The pelvis is tilted anteriorly approx.15

degrees.• Minimal motion of anterior tilt.• When Hamstrings are tight,pelvis assumes

posterior tilt.• The hip is flexed at initial contact &

extends during stance phase.• The hip continues to flex during swing

phase.

• The Knee at initial contact,knee flexes approx.15 degrees & acceptance of body weight through knee flexion.

• The Knee extends passively during swing phase.

• Deviations range from hyperextension of knee in stanse phase if heel cord is tight,to flexion in stanse phase due to tight hamstrings,to inability to flex knee in swing phase due to inappropriate rectus femoris.

Ankle sagittal plane kinematics starts with a neutral ankle at initial contact.

Rocker 1(heel)

• Heel strikes ground• Then ankle plantar

flexes 5 to 10 degrees.

• Receives body weight at heel

Rocker 2 ( ankle)

• Ankle dorsiflexes• Tibia moves forward• Transfers the body

weight to fore foot

Rocker 3 ( fore foot)

• Ankle plantar flexes• Heel rises for push off

CORONAL PLANE:

• Hip - Pelvic obliquity seen. - Pelvic rise must be

accoumpanied by a contralateral fall,so in stance phase hemipelvis drops slightly.

TRANSVERSE PLANE:

• It measures rotation.• FOOT

PROGRESSION ANGLE: is the angle foot makes with path the subject is walking

DETERMINANTS OF GAIT

Pelvic Rotation: • In normal gait,pelvis rotates 8 degrees

within transverse plane of body i,e. 4 degrees forward on swing leg & 4 degrees posteriorly on stance leg.

Pelvic List:

• Pelvic rotates within the frontal plane of body during gait, k/as Pelvic List.

• Leads to adduction of weight bearing limb & abduction of non weight bearing limb thereby improving effeciency of hip-abductor mechanism.

KneeFlexion In Stance Phase:

• The knee should remain flexed during all components of stance phase(except heel strike) to prevent exceessive vertical displacement of center of gravity.

• Reduces vertical displacement of center of gravity as of body is carried forward over stance limb.

Foot and Ankle Motion:

• Smooths out path of centre of graity when coupled with knee motion.

Knee Motion:

Smooths out path of centre of graity when coupled with foot & ankle motion.

Lateral Displacement of Pelvis:

• Reduces lateral movement of centre of gravity toward stance foot during gait cycle.

MUSCLE ACTIVITY• Concentric contraction- - muscle

shortens on stimulation, generates power and accelerates body forward.

-gastrosoleus contracts to lift the heel off the ground -iliopsoas contracts flexing the hip and pulling the stance phase limb off the ground

• Eccentric contraction- muscle lengthens on stimulation, slows down and stabilises joint motion

-tibialis anterior-contracts at initial contact ,firing during plantar flexion as the foot is lowered to ground, so the foot is gently lowered to ground -gastrosoleus-contracts eccentrically through the stance phase controlling

rate of dorsiflexion of ankle.

KINETICS OF GAIT• It is the study of forces that produces a

change in motion.• It is concerned with internal forces

developed within body by muscular action as well as forces acting in body.

External forces includes:• Centre of gravity• Ground reaction forces

Centre of gravity:• It is imaginary point at which all weight of

body is concentrated at a given instant.• The body of gravity lies two inches in front

of SECOND SACRAL VERTEBRA.• It follows up & down movements as well as

side to side.• Due to complex interaction of muscular

activity & joint motion in lower extremity it follows a SMOOTH SINUSOIDAL CURVE.

Ground reaction forces:• It is a line represents the direction &

magnitude of force encountered by the body at heel strike.

• The length of vector is proportionate to the magnitude of force.

• The ground reaction force horizontal & vertical can be measured by force plateforms(force plates).

GAIT IN YOUNG• Main ways in which gait of small children

differs from that of adult are as follows:• The walking base is wider.• The stride length & speed are lower & the

cycle time shorter(higher cadence).• Small children have no heel strike,initial

contact being made by flat foot.

• There is very little stance phase knee flexion.

• The whole leg is externally rotated during the swing phase.

• There is an absence of reciprocal arm swinging.

• The above list will change to adult pattern by age of 2 to 4yrs.

GAIT IN ELDERLY• The age related changes in gait takes

place in decade from 60 to 70yrs.

• There is a decreased stride length, increased cycle time(decreased cadence).

• Relative increase in duration of stance phase of gait cycle.

• An increase in walking base.

• The speed almost always reduced in elderly people.

• Reduction in total range of hip flexion & extension,a reduction in swing phase knee flexion & reduced ankle plantar flexion during the push off.

BENEFITS OF GAIT ANALYSIS

• To diagnose mechanisms responsible for gait disorders.

• To asses degree of disability.• To evaluate the improvement resulting

from teratment.• Evaluation of the rate of deterioration in

progressive disorders that affects gait.• Quantification for clinical & research.

PATHOLOGIC GAIT • Divided into neurovascular or

musculoskeletal etiologies

• LIMPING:In this,patient avoids weight bearing on affected side as far as possible. i,e. diminished stance phase.

• It denotes a painful condition of affected side.

• LURCHINNG:In this patient prolongs stance phase to improve the stability.

• It denotes variable failure of abduction mechanism.

Abnormal gait may be due to:• MUSCLE WEAKNESS• STRUCTURAL DEFORMITIES OF BONE &

JOINT• NEUROLOGICAL DISORDERS• MISCELLANEOUS

MUSCLE WEAKNESS CAUSING PATHOLOGIC GAIT:

GLUTEUS MEDIUS GAIT(Abduction Lurch):

• Gluteus Medius is principal abductor of hip joint along with obturator internus & piriformis.

• The weakened Gluteus Medius forces patient to lurch towards involved side to place centre of gravity over hip.

• This is called Gluteus Medius Gait.

TRENDELENBURG GAIT:• The stability of hip during walking provided

by bony components of joint,muscles & around joint & normal alignment of centre of gravity.

• any disruption in the osseo muscular mechanism between pelvis & femur leads to lost of stability of hip joint.

• The action of abductor in pulling downwards in stance phase become ineffective.

• As a result patient lurches on affected side & pelvis drops on opposite side of hip.

• seen in polio,CDH, perthes disease,coxa vara,muscular distrophies.

GLUTEUS MAXIMUS LURCH:

• Gluteus maximus is the chief extensor & lateral rotator of hip.

• Normally when body moves forward in mid stance phase,the hip is extended by gluteus maximus tilting pelvis backwards to retain centre of gravity over supporting leg.

• When there is weakness of gluteus maximus muscle the stabilizing factor is lost & patient leans backwards at hip to passively extend it & keep centre of gravity over stance leg.

• This causes backward lurch in gluteus maximus gait.

• Patient walks with protruberant abdomen.• Seen in poliomyelities & above knee

amputation with prosthesis.

QUADRICEPS GAIT:• Quadriceps muscle is the principal

extensor of the knee joint.• Due to weakness of quadriceps muscle,

the affected limb is put forward in stepping with the body leaning toward it anteriorly.

• Patient gradually learns to stabilize his knee by directly transferring his body weight over lower thigh,through his ipsilateral hand.

• Weakness of quadriceps is most apparent during heelstrike through the stance phase.

• The limp affects all phases of gait cycle.

• Extension at femur results in flexion of the trunk & an extension movement at knee.

CALCANEAL GAIT:• It occurs due to

weakness of the gastrocnemius-soleus muscle group.

• As a result,reduced foot propulsion occurs during toe off period of the stance phase & patient walks on his broadened heel with a tendency of rotating foot outwards.

WEAKNESS OF HIP FLEXORS:• The patient will have difficulty in initiating

swing through.• To compensate for this specific muscular

weakness patient externally rotates leg & uses hip adductors for swing through.

• This circumduction of hip exaggerates energy expenditure & produces extreme trunk & pelvis motion.

HIGH STEPPING GAIT:• Ankle dorsiflexors act during the swing

phase of cycle.• The weakness of this group of muscles

causes foot drop.• During walking foot slap in ground on heel

strike & then drops in swing phase.• To prevent this patient flexes hip & knee

excessively in order to clear the ground.

STRUCTURAL DEFORMITIES OF BONE & JOINT

ANTALGIC GAIT:• Any pathology in lower extremity which

causes during weight bearing result in antalgic gait.

• To minimize pain on weight bearing, person shortens time duration of stance phase on painful side & quickly transfers weight on normal leg.

• Longer stance on normal leg & shorter stance on painful leg.

STIFF HIP GAIT:• When the hip is

ankylosed, it is not possible to flex at hip joint walking to clear the ground in stance phase,hence person with stiff hip lifts pelvis on that side & swings leg in circumduction to take the forward step.

SHORT STEP:

• A limb length discripancy of 1 to 1.5 inch is compensated by tilt of the pelvis,which is demonstrated by a low shoulder,low iliac crest & low ASIS.

• Another method to compensate shortening is to put foot & ankle at the affected side into equinus position & hip & knee of normal limb in flexion.

NEUROLOGICAL DISORDERS

HEMIPLEGIC/FLACCID GAIT:• In a hemiplegic gait,the shoulder is

adducted & the elbow & wrist are flexed.• The pateint swings the paraplegic gait

outwards & aheads in a circumduction to avoid foot scraping ground.

• It is seen in cerebrovascular disease.

• SCISSORING/SPASTIC GAIT:• This gait is characteristic of gait of a

spastic child with marked b/l adductor spasm at hip & equinus in the ankle.

• The child needs support to walk & leg goes into marked adduction in swing phase so that the foot with equinus goes across to opposite side.

• Such repeated crossing of leg whle walking gives scissoring appearance called as scissor gait.

FESTINANT GAIT:• The steps are short so that feet barely

clear floor.• If patient is pushed backward or forward,

compensatory flexion or extension fails to occur & patients is forced to make a series of propulsive or retropulsive steps with forward locomotion.

• Steps become successively more rapid as if trying to catch up with centre of gravity.

• Seen in Parkinson's disease.

STAMPING/ATAXIC GAIT:• It occurs in sensory ataxia in which there

is loss of sensation in lower extremity due to disease processes in peripheral nerves, dorsal roots, dorsal column of spinal cord.

• Due to absence of deep position sense,the patient constantly observes placing of his feet.

• Hip is hyperflexed & externally rotated & forefoot is dorsiflexed to strike ground with a Stamp.

• Seen in peripheral neuritis & brain stem lesion in children, tabes dorsalis in adults.

DRUNKARDS/REELING GAIT:

• The patient tends to walk irregularly on a wide base sways from side to side with tendency of falling with each step.

• It is seen in lesion of cerebellum, lesion connecting pathway to & from the cerebellum.

CHOREFORM GAIT:

• In this patient will be having chorea in upper limbs & has a unstable gait.

• Seen in patients having extrapyramidal symptoms.

MISCELLANEOUS GAIT

ALDERMAN'S GAIT :

• Patient walks with head & chest thrown backwards & protuberant & walks with legs thrown wide apart.

• Seen in Tuberculosis spine of lower dorsal & lumbar vertebrae.

HYSTERICAL GAIT:• Patient walks in a bizzare as if going to fall

on every step but seldom falls and walks cautiously.

KNOCK KNEE GAIT:• The patient flexes his hip slightly the knee

joint opposes each other, the ankle & feet are kept apart with tendency of toe in.

SENILE GAIT:• Changes in gait & difficulty with balance

occurs with aging.• Elderly man develops forward of upper

portion of trunk with flexion of arms & knees.

• Decreasing arm swing & shortening of step length.

CRUTCH WALKING-PATTERNS OF GAIT

There are 4 patterns of gait:• Swinging crutch gait - in paraplegics• Four point crutch gait - in unsteady pts.• Two point crutch gait - pts.balance good• Three point crutch gait

Swinging crutch gait :• There are two types of swinging crutch

gaits, the swing to crutch gait & swing through crutch gait.

• These gaits are when body weight can be taken through both lower limbs together but patient is incapable of moving lower limbs individually due to paralysis.

• The lower limbs are moved by trunk muscles acting on the pelvis.

Swing Through Crutch Gait:

• In this body is swing through beyond the crutches.

• Fastest gait,requires functional abdominal muscles.

Swing to Crutch Gait:• In this pt. advances

the crutches & then swings his body to the crutuhes.

The sequence of events:

• both crutches both lower limbs.

Four point crutch gait:• It is used when all or part of body weight can

be taken on each foot.• Pt. is unsteady & requires a wide base of

support.• As pt's balance improves he may progress

to two point crutch gait.• The four points are two crutch tips & two

limbs.Sequence of events:• right crutch left foot left crutch right

foot.

Two point crutch gait:

• When two point crutch gait is used,the amount of body weight taken on both feet is reduced.

• This type of gait used when pts. balance is good.

Sequence of events:

• Right crutch & left foot simultaneously f/by

• left crutch & right foot simultaneously.

Three point crutch gait:

• In this gait, the amount of body weight taken by a foot can vary from none to partial or full.

• This gait is commonly taught to orthopaedic patients who may have one painful or weak limb which cannot support the whole body weight & one lower limbs which can.

• Both crutuhes support weaker lower limb, while the stronger limb takes whole body weight without any support from the crutches.

Sequence of events:• Both crutches & the weaker lower limb

together, the stronger lower limb.

DHANYAVAAD DR.RAMACHANDRA